“STUD

TH

M

TH

DY ON

PR

Su

HE TAMI

GOVER

MD (PSY

HE TAMI

A

DELIR

ROFILE

ubmitted fo

ILNADU D

CHE

RNMENT K

C

CHIATR

B

ILNADU D

CHEN

A Disserta

RIUM-

E AND

or M.D. D

Dr. M.G.R

NNAI, TA

KILPAUK

CHENNAI

RIC MEDI

BRANCH

Dr. M.G.R

NNAI, TA

May 202

ation on

ETIOL

OUTC

Degree exam

R. MEDICA

AMILNAD

K MEDICA

I-600010

ICINE) E

– XVIII

R. MEDICA

AMILNAD

20

LOGY,

COME”

minations

AL UNIV

DU

AL COLL

EXAMINA

AL UNIV

DU.

CLINIC

”

VERSITY,

LEGE,

ATION

VERSITY,

CAL

BONAFIDE CERTIFICATE

This to certify that the Dissertation entitled “STUDY ON

DELIRIUM- ETIOLOGY, CLINICAL PROFILE AND

OUTCOME” is a bonafide record of work done by

Dr.C.J.DHIINESH in the department of Psychiatry, Government

Kilpauk Medical College, Chennai, during his Post Graduate Course from

2017 to 2020. This is submitted as partial fulfilment for the requirement

of M.D. Degree examinations – Branch – XVIII (Psychiatry) to be held

in May 2020.

Prof. Dr. P. Vasanthamani, Prof. Dr. M. Malaiappan, MD,

MD, DGO, MNAMS, MBA., Professor and Head,

The Dean, Department of Psychiatry,

Govt. Kilpauk Medical College, Govt. Kilpauk Medical College,

Chennai. Chennai

CERTIFICATE

This is to certify that “STUDY ON DELIRIUM- ETIOLOGY,

CLINICAL PROFILE AND OUTCOME” is a bonafide work of

Dr.C.J.DHIINESH in partial fulfilment of the requirements for the M.D

Psychiatric Medicine examination (Branch-XVIII ) of the Tamilnadu

Dr. M.G.R Medical University, Chennai, to be held in May, 2020.

GUIDE & HEAD OF THE DEPARTMENT Dr. MALAIAPPAN MD,

Professor& HOD

Department of Psychiatric Medicine,

Kilpauk Medical College,

Chennai.

DECLARATION

I, Dr. C.J.DHIINESH, solemnly declare that the dissertation titled

“STUDY ON DELIRIUM- ETIOLOGY, CLINICAL PROFILE

AND OUTCOME” is a bonafide work done by me in Government

Kilpauk Medical College, Chennai, during March 2018 – September -

2019 under the guidance and supervision of

Prof. Dr M. MALAIAPPAN, MD (Psychiatry).

This dissertation is submitted to “The Tamilnadu Dr M.G.R.

Medical University, Chennai”, Tamilnadu as a partial fulfillment for the

requirement of M.D. Degree examinations – Branch – XVIII (Psychiatry)

to be held in May 2020.

Place: Chennai

Date: (Dr. C.J.DHIINESH)

Urkund Analysis Result Analysed Document: Study on Delirium- etiology, clinical profile and outcome 2.docx

(D58076191)Submitted: 11/1/2019 4:35:00 PM Submitted By: cjdinesh20@gmail.com Significance: 23 %

Sources included in the report:

7fe579f8-58b6-4862-ae17-926437b89d25 80cdabda-2bf3-47e4-be64-fd8842f80282 6b4acd7b-cac8-4271-ae54-69b23eb38977 92c2b4eb-bae4-4d5b-9b16-7be0bbed9559 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5028550/

Instances where selected sources appear:

32

U R K N DU

CERTIFICATE – II

This is to certify that this dissertation work titled “STUDY ON

DELIRIUM- ETIOLOGY, CLINICAL PROFILE AND

OUTCOME” of the candidate Dr. C.J.DHIINESH with Registration

Number: 201728351 for the award of M.D in the branch of

PSYCHIATRIC MEDICINE. I personally verified the urkund.com

website for the purpose of plagiarism check. I found that the uploaded

thesis file contains from introduction to conclusion pages and result

shows 23% percentage of plagiarism in the dissertation.

GUIDE & SUPERVISOR SIGN

WITH SEAL

Place: Chennai

Date:

ACKNOWLEDGEMENTS

I am very grateful to My Guide Dr. M. MALAIAPPAN, without

whose patience and constant motivation, this work would not be possible.

My Professor Dr JAYAKRISHNAVENI, for her invaluable help in

completing this thesis.

My Assistant Professors Dr. Sharon Joe Daniel, Dr. Bakyaraj and

Dr. Vamsi Sreenivas for their valuable opinion and constructive

suggestions during the planning and analysis of this research work.

My Assistant Professor Dr.A.P. Mythili for her guidance and

suggestions.

All the patients and their family members who co-operated for the

study.

All my colleagues and my family for their support and

encouragement.

TABLE OF CONTENTS

S.NO TOPIC PAGE NO

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 2

3 REVIEW OF LITERATURE 3

4 METHODOLOGY 34

5 STATISTICAL ANALYSIS 41

6 RESULTS 43

7 DISCUSSION 74

8 CONCLUSION 80

9 LIMITATIONS 82

10 BIBLIOGRAPHY

11 ANNEXURE

LIST OF TABLES

TABLE

NO

TITLE OF TABLE PAGE

1 Total socio demographic data 44

2 various blood parameter 47

3 Longitudinal analysis using Drs-98 scale,

measured 48 hours apart

48

4 Total frequency of DRS -98 items of severity

and moderate or severe severity

50

5 Frequency of cognitive test for delirium 51

6 Mean of CTD, DRS R-98,SADQ and BPRS 53

7 Correlation between cognitive test for Delirium

and Delirium rating scale -98

54

8 Duration Of delirium, hospital ,treatment and

outcome

57

9 Medical cause of delirium 59

10 Frequency of subtype of motor agitation and

retardation

61

11 Descriptive data of alcohol withdrawal delirium 63

12 Compare the medical and alcohol withdrawal

delirium, Age and Delirium Cause.

64

13 Comparison of demographic details between

alcohol withdrawal and medical illness delirium

66

14 Comparison of frequency of symptom profile

and severity between groups

68

15 Duration of delirium comparison between both

groups

70

16 Independent Samples Test between Delirium

Cause and Total duration of delirium

71

17 Treatment and outcome of delirium between

two groups

72

18 Independent Samples Test between Delirium

Cause and Total duration of Hospital

73

LIST OF FIGURES

Figure

No

TITLE OF FIGURE Page No

1 Frequency of subject obtained 43

2 Frequency of socio demographic score 46

3 SURFACE Diagram frequency of DRS -98 49

4 Bar chart showing frequency of cognitive test for

delirium

52

5 Pie chart showing outcome of the delirium 58

6 Bar chart showing distribution Medical cause of

delirium

60

7 Bar chart Compare the Age of medical and alcohol

withdrawal delirium

65

8 Surface diagram depicting mean difference between

alcohol withdrawal Delirium and other cause of

medical delirium

67

1

“STUDY ON DELIRIUM- ETIOLOGY, CLINICAL

PROFILE AND OUTCOME”

INTRODUCTION

Delirium is an acute confusional state. The onset is rapid and has

fluctuating course. It presents with alterations in consciousness and

disturbance in sleep wake cycle, thinking and memory, disordered

attention, hallucinations and delusions, and physical agitation or hypo

activity. The cause of it may be neurological or psychological and the

presentation also varies between them according to Daniel et al., This

study was conducted over period of one year for detailed evaluation

delirium related phenomenology and its outcome .The aim of the study is

to strengthen our knowledge of this highly prevalent yet poorly studied

condition by assessing the phenomenology (psychological and physical

event) both cross -sectionally and longitudinally during course of an

episode

2

AIM OF THE STUDY

Aim

• To Study clinical profile of delirium associated with alcohol

withdrawal Vs other medical illness - its, course of illness & outcome.

Objective

• To asses symptom profile and course of alcohol withdrawal –

delirium

• To asses symptom profile and course of other medical illness –

delirium

• To compare clinical profile of delirium associated with alcohol

withdrawal Vs other medical illness - its, course of illness &

outcome

• To assess the correlation of cognitive status and psychotic symptom

3

REVIEW OF LITERATURE

Acute confusion state is a multidimensional neurological and

psychological condition, incidence in general medical inpatients is 11-

42% of Siddiqi et al, 2006 and in hospitalized geriatric population the

incidences is about 50% Cole, 2004 and this increases for those who have

pre-existing deficits in cognition, fatal illness or those who are admitted

in ICU (Cole, 2004; Ely et al, 2001; Lawlor 2000). Delirium was the

most common presentation of disease in the elderly (Bucht, Gustafson,

and Sandberg 1999). Acute confusion states have crucial symptoms for

diagnosis like disorganised thinking and inattention, the other important

features includes motor activity change and disturbance sleep-wake

rhythm .some variable presentation include mood changes and psychosis

.the presentation also varies depending upon cause ,other co morbidities

,the treatment provided and patient susceptibility factors.

Hippocrates referred to it as pbrenitis, the origin of the word

frenzy. In the first century AD, Celsus introduced the term delirium (De-

lira) from the Latin for " to be displaced from one’s furrow," meaning

derailment of the mind, and Aretaeus of Cappadocia, a contemporary of

Celsus, was perhaps the first to classify mental disorders into acute and

chronic categories .Galen observed that delirium is often due to physical

4

diseases that affects the mind "sympathetically." In the nineteenth

century, Gower’s found that these patients could he either lethargic (hypo

active) or hyperactive. Barrough proposed that delirium constituted a

impairment of three main internal senses: including memory, cognition

and imagination. Thomas Willis in his book 1672 treatise De Anima

Brutorum stated delirium is a specific set of symptoms and not a disease.

John Hunter defined delirium as “a cessation of consciousness” of one’s

own existence. Bonheoffer, in his classification of organic behavioral

disorders, established that delirium is associated with clouding of

consciousness. Finally, Kngel and Romano described alpha slowing and

delta and theta intrusions on electroencephalograms (LLCs) and

correlated these change with clinical severity. They also noted that

treating the medical cause resulted in reversal of both the clinical feature

and the EEG changes of delirium.

Glossary of term

Many terms used to describe this disorder:

Acute brain failure,

Acute brain syndrome,

Acute cerebral insufficiency,

Acute confusional state,

Acute organic syndrome,

5

Delirium,

Encephalitis,

Encephalopathy,

Intensive care unit psychosis,

Toxic metabolic state,

Central nervous system toxicity,

Para neoplastic limbic encephalitis,

Sun downing,

Cerebral insufficiency,

Organic brain syndrome,

Exogenous psychosis,

Metabolic encephalopathy,

Organic psychosis,

Toxic encephalopathy,

Toxic psychosis,

Major Problems in recognizing delirium is defining the disorder.

Delirium mostly reflects a global failure of brain metabolism from a large

variety of medical etiologies, yet it is difficult to judge the impact of

medical conditions on the brain.

6

Delirium may lead to

Delay in postoperative mobilization,

Prevention of early rehabilitation,

Increased rate of nursing home placement,

Increased need for home care services,

Increased distress to caregivers

Risk Factors for Delirium

Risk factors for delirium is categoried into two , predisposing and

precipitating factors

Predisposing

Demographics

Age more than 65,

Male sex.

Pervious Cognitive status

Dementia,

Cognitive impairment,

History of delirium.

7

Functional status

Functional dependence,

Immobility,

History of falls,

Low level of activity.

Sensory impairment

Hearing,

Vision.

Decreased oral intake

Dehydration,

Malnutrition.

Drugs

Treatment with psychotropic drugs,

Treatment with drugs with anticholinergic properties,

Alcohol abuse.

Coexisting medical conditions

Severe medical diseases,

Chronic renal or hepatic disease,

8

Stroke,

Neurological disease,

Metabolic abnormalities,

Infection with HIV,

Fractures or trauma.

Precipitating Factors for Delirium

Drug induced as like with

Sedative hypnotics,

Narcotics,

Anticholinergic drugs,

Polypharmacy,

Alcohol or drug withdrawal.

Primary neurologic diseases like

Stroke,

Nondominant hemispheric Intracranial bleeding,

Meningitis or Encephalitis.

Intercurrent illnesses like

Infections,

Iatrogenic complications,

Severe acute illness,

Hypoxia,

9

Hyponatremia,

Shock,

Anemia,

Fever or hypothermia,

Dehydration,

Poor nutritional status,

Low serum albumin levels,

Metabolic derangements.

Surgical procedures like

Orthopedic surgery,

Cardiac surgery,

Prolonged cardiopulmonary bypass,

Non cardiac surgery.

Environmental factors like

Admission to intensive care unit,

Use of physical restraints,

Use of bladder catheter,

Use of multiple procedures,

Pain,

Emotional stress,

Prolonged sleep deprivation.

10

Protective Factors

Good pre morbid functioning before delirium predicts better

outcomes. Educational programs that target clinicians, consultants,

clinical staffs and primary care providers giving training and creating

awareness regarding the disorder among them demonstrated benefit.

Placement of liaison psychiatrists on others specialty orthopedic units

improved coordination of care. Other interventions such as a focus on

nutrition, increased rehabilitation, and attention to visual and hearing

impairment

PATHOPHYSIOLOGY

Their exist heterogeneity in etiologies and the presentations of

delirium. There may not be one mechanism that encompasses the entire

syndrome. Disturbance in brain oxygen supply versus demand has been

one of the theories proposed for delirium. Impaired oxidative metabolism

appears to be a predisposing factor for later development of delirium.

EEG studies have demonstrated diffuse slowing of cortical background

activity, which does not correlate with underlying causes.

11

Neuropsychologic and Neuroimaging studies revealed, in the non

dominant brain generalized disruption in higher cortical function, with

dysfunction in the prefrontal cortex, subcortical structures, thalamus,

basal ganglia, frontal and temporoparietal cortex, fusiform cortex and

lingual gyri

There was two hypotheses to understanding into the complex

pathophysiology of delirium.

1. Neurochemical imbalances

2. Inflammation

Acetylcholine

Cholinergic deficiency is found to be associated with delirium as it

is involved in rapid eye movement (REM) sleep, attention, arousal, and

memory. Administration of anticholinergic drugs can induce delirium in

humans and animals, and serum anticholinergic activity is increased in

patients with delirium. Physostigmine a cholinergic agent reverses

delirium associated with anticholinergic drugs and also in delirium from

alcohol withdrawal, ketamine in anesthesia, H2 receptor antagonist

delirium, and γ -hydroxybutyric acid withdrawal.

12

Dopamine

Dopaminergic drugs and bupropion are recognized precipitants of

delirium, and dopamine antagonists (e.g., antipsychotic agents)

effectively treat delirium symptoms. Dopaminergic excess also appears to

contribute to delirium, possibly owing to its regulatory influence on the

release of acetylcholine

Glutamate.

Wernicke encephalopathy presenting with delirium showed

glutamate abnormalities. Excitatory neurotoxic effects(mediated via the

N-methyl-D-aspartate [NMDA] receptor), may cause neuronal death and

can be associated with delirium

γ-Aminobutyric Acid

Delirium secondary to benzodiazepine and alcohol withdrawal

associated with abnormalities in GABA

Hepatic encephalopathy is caused by many factors and associated

with increased GABA and serum ammonia levels.

Ammonia and metabolites are known to induce and aggravate

astrocyte swelling that initiate a cascade of events leading to delirium. In

elevated ammonia levels can contribute to increased glutamate and

glutamine levels, which are precursors to GABA.

13

Inflammation

CNS response to systemic inflammation during a state of blood–

brain barrier compromise

Cytokines

Interleukin-1 (IL-1), IL-2, IL-6, tumor necrosis factor-α (TNF-α),

and interferon which alter the permeability of the blood–brain barrier and

neurotransmission after trauma, primary hyperparathyroidism, delirium

tremens and post cardiac surgery

Chronic Stress.

Chronic stress activates the sympathetic nervous system and

hypothalamic–pituitary– adrenocortical axis which results in increased

cytokine levels and chronic hypercortisolism. Chronic hypercortisolism

has deleterious effects on hippocampal serotonin 5-HT1A receptors.

ETIOLOGIES

Major causes of delirium

Metabolic Hepatic encephalopathy, uremia, hypoglycemia,

disorders hypoxia, hyponatremia, hypocalcemia/ hypercalcemia,

Hypomagnesemia/ hypermagnesemia, other electrolyte disturbances,

acidosis, hyperosmolar coma, endocrinopathies (thyroid, parathyroid,

14

pituitary), porphyria, vitamin deficiencies (thiamine, vitamin

R|2,nicotinic acid, folic acid), toxic and industrial exposures (carbon

monoxide, organic solvent, lead, manganese, mercury, carbon disulfide,

heavy metals)

Drug related Withdrawal syndromes (alcohol, benzodiazepines,

barbiturates, other), amphetamines, cocaine, coffee, phencyclidine,

hallucinogens, inhalants, meperidine and other narcotics,

antiparkinsonism drugs, sedative hypnotics, corticosteroids,

anticholinergic andantihistaminic drugs, cardiovascular agents

(betablockers, clonidinc, digoxin), psychotropics (phenothiazines,

clozapine, lithium, tricyclicantidepressants, trazodone), 5-fluorouracil

andcytotoxic antineoplastics, anticonvulsants(phenobarbital, phenytoin,

valproate), cimetidine, disulfirarn, ergot alkaloids, salicylates,

methyldopa, and selected antiinfectiousagents (acyclovir, amphotericin

B,cephalexin, chloroquine, isoniazid, rifampin)

Infections Meningitis, encephalitis, brain abscess, neurosyphilis,

Lyme neuroborreliosis, cerebritis, systemic infections with septicemia.

Neurological Strokes, epilepsy, head injury, hypertensive

encephalopathy, brain tumors, migraine, otherneurovascular disorders.

15

Perioperative Specific surgeries (cardiac, orthopedic,

ophthalmologics!), anesthetic and drug effects, hypoxia and anemia,

hyperventilation, fluid and electrolyte disturbances, hypotension,

embolism,infection or sepsis, pain, fragmented sleep, sensory deprivation

or overload.

Miscellaneous Cerebral vasculitidcs, paraneoplastic and

limbicencephalitis, hyperviscosity syndromes, trauma,cardiovascular,

dehydration, sensory deprivation

DIAGNOSIS

Approaches to Diagnosis

The underlying cause of delirium might present as occult or

atypical presentations of many diseases in the elderly, including

myocardial infarction, infection, and respiratory failure as delirium is

often the sole manifestation of serious underlying disease. Initial step

preadmission and current medications should be reviewed for indication

and risk: benefit such as long-standing medications can contribute to

delirium and should be reevaluated. Detail medical history and substance

abuse (occult alcohol or benzodiazepine use), which can contribute to

delirium be elevated.

16

ICD-10

F05 Delirium, not induced by alcohol and other psychoactive

substances

An etiologically nonspecific syndrome characterized by concurrent

disturbances of consciousness and attention, perception, thinking,

memory, psychomotor behaviour, emotion, and the sleep-wake cycle. It

may occur at any age but is most common after the age of 60 years. The

delirious state is transient and of fluctuating intensity; most cases

recover within 4 weeks or less. However, delirium lasting, with

fluctuations, for up to 6 months is not uncommon. Especially when

arising in the course of chronic liver disease, carcinoma, or sub acute

bacterial endocarditis. The distinction that is sometimes made between

acute and sub acute delirium is of little clinical relevance; the condition

should be seen as a unitary syndrome of variable duration and severity

ranging from mild to very severe. A delirious state may be superimposed

on, or progress into, dementia. This category should not be used for states

of delirium associated with the use of psychoactive drugs specified in

F10-F19. Delirious states due to prescribed medication (such as acute

confusional states in elderly patients due to antidepressants) should be

coded here. In such cases, the medication concerned should also be

recorded by means of an additional T code from ICD-10.

17

Diagnostic guidelines For a definite diagnosis, symptoms, mild or

severe, should be present in each one of the following areas:

(a) Impairment of consciousness and attention (on a continuum from

clouding to coma; reduced ability to direct, focus, sustain, and shift

attention);

(b) Global disturbance of cognition (perceptual distortions, illusions and

hallucinations

- most often visual; impairment of abstract thinking and comprehension,

with or without transient delusions, but typically with some degree of

incoherence;

impairment of immediate recall and of recent memory but with

relatively intact remote memory; disorientation for time as well as, in

more severe cases, for place and person);

(c) Psychomotor disturbances (hypo- or hyperactivity and unpredictable

shifts from one to the other; increased reaction time; increased or

decreased flow of speech; enhanced startle reaction);

18

(d) Disturbance of the sleep-wake cycle (insomnia or, in severe cases,

total sleep loss or reversal of the sleep-wake cycle; daytime drowsiness;

(e)emotional disturbances, e.g. depression, anxiety or fear, irritability,

euphoria, apathy,or wondering perplexity.

The onset is usually rapid, the course diurnally fluctuating, and the

total duration of the condition less than 6 months. The above clinical

picture is so characteristic that a fairly confident diagnosis of delirium

can be made even if the underlying cause is not clearly established. In

addition to a history of an underlying physical or brain disease,

evidence of cerebral dysfunction (e.g. an abnormal

electroencephalogram, usually but not invariably showing a slowing of

the background activity) may be required if the diagnosis is in doubt.

Includes: acute brain syndrome

acute confusional state (nonalcoholic)

acute infective psychosis

acute organic reaction

acute psycho-organic syndrome

19

Differential diagnosis. Delirium should be distinguished from other

organic syndromes, especially dementia (F00-F03), from acute and

transient psychotic disorders (F23.-), and from acute states in

schizophrenia (F20.-) or mood [affective] disorders (F30-F39) in which

confusional features may be present. Delirium, induced by alcohol and

other psychoactive substances, should be coded in the appropriate

section (F1x. 4).

F05.0 Delirium, not superimposed on dementia, so described

This code should be used for delirium that is not superimposed upon

pre-existing dementia.

F05.1 Delirium, superimposed on dementia

This code should be used for conditions meeting the above criteria but

developing in the course of a dementia (F00-F03).

F05.8 Other delirium

Includes: delirium of mixed origin sub acute confusional state or delirium

20

F05.9 Delirium, unspecified

1x.4 Withdrawal state with delirium

A condition in which the withdrawal state (see F1x.3) is

complicated by delirium

Alcohol-induced delirium tremens should be coded here.

Delirium tremens is ashort- lived, but occasionally life-threatening, toxic-

confusional state with accompanying somatic disturbances. It is usually a

consequence of absolute or relative withdrawal of alcohol in severely

dependent users with a long history of use. Onset usually occurs after

withdrawal of alcohol. In some cases the disorder appears during an

episode of heavy drinking, in which case it should be coded here.

Prodromal symptoms typically include insomnia, tremulousness, and fear.

Onset may also be preceded by withdrawal convulsions. The classical

triad of symptoms includes clouding of consciousness and confusion,

vivid hallucinations and illusions affecting any sensory modality, and

marked tremor. Delusions, agitation, insomnia or sleep-cycle reversal,

and autonomic over activity are usually also present.

21

Excludes: delirium, not induced by drugs and alcohol (F05.-)

The diagnosis of withdrawal state with delirium F1x.40 Without

convulsions F1x.41 With convulsions

CLINICAL FEATURES

Attention

Attention is the ability to focus on specific stimuli to the exclusion

of others. the aspect of consciousness that relates to the amount of effort

exerted in focusing on certain aspects of an experience, activity, or task.

Arousal, a basic prerequisite for attention, indicates

responsiveness or excitability into action.

Coma, stupor, wakefulness, and alertness arc states of arousal

Awareness and alertness are maintained by the ascending reticular

activating system in the brainstem which projects to the thalamus and

cortex; a bilateral frontal and parietal cortical network enables selective

attention to particular events and types of stimuli, and divided attention to

multiple events and stimuli. This cortical control system modulates

activity in sensory cortices as well as the motor areas involved in

response preparation. The distributed brain networks that regulate

22

attention are vulnerable to many different disease processes. Deficits of

attention are a cardinal feature of delirium Acute Onset with Fluctuating

Course

Delirium onset rapidly over hours or days but rarely over more

than a week and fluctuations in the course occur throughout the day.

There are lucid intervals interspersed with the daily fluctuations. Gross

swings in attention, arousal, or both occur unpredictably and irregularly

and become worse at night.

Attention is the most common and cardinal symptom of delirium.

Clinical feature of are distractible, and stimuli may gain attention

indiscriminately, trivial ones often getting more attention than important

ones. All components of attention ate disturbed, including selectivity,

sustainability, processing capacity, case of mobilization, monitoring of

the environment, and the ability to shift attention when necessary.

Disorganized Thinking

In delirium stream of thought is disturbed, there are multiple

intrusions of competing thoughts and sensations, and patients are unable

23

to order symbols, carry out sequenced activity, and organize goal-directed

behavior .Confusion defined as inability to maintain the stream of thought

with accustomed clarity, coherence, and speed. Decreased relevance of

the speech content and decreased reading comprehension is characteristic

of delirium. Confused speech is further characterized by an abnormal

rate, frequent dysarthria, and nonaphasic misnaming, particularly of

words related to stress or illness, such as those referable to

hospitalization. Speech reflects this jumbled thinking. Speech shifts from

subject to subject and is rambling, tangential, and circumstantial, with

hesitations, repetitions, and perseverations.

Altered Level of Consciousness

Consciousness or clarity of awareness Most patients have lethargy

and decreased arousal. In hyper alert patients, the extreme arousal does

not preclude in attention deficits because patients are indiscriminate in

their alertness, are easily distracted by irrelevant stimuli, and cannot

sustain attention. The two extremes of consciousness may overlap or

alternate in the same patient or may occur from the same causative factor

24

Delirium in Patients with Dementia

Dementia is the leading risk factor for delirium, and fully two-

thirds of cases of delirium occur in patients with dementia. Underlying

vulnerability of the brain in patients with dementia may predispose them

to the development of delirium as a result of insults related to acute

medical illnesses, medications, or environmental perturbations. Delirium

and dementia are both associated with decreased cerebral metabolism,

cholinergic deficiency, and inflammation, reflecting their overlapping

clinical, metabolic, and cellular mechanisms. The prevalence of delirium

increased according to the severity of the patient’s prior cognitive

impairment. Except for disorganized thinking, all symptoms of delirium

were similar among patients with mild, moderate, and severe prior

cognitive impairment. training nurses to recognize subtle changes in

mental status among those patients who were older with prior cognitive

impairment may prevent the under detection of delirium.

Jackson et al treating the underlying reversible cause of delirium

brings the patient’s functional and cognitive status back to premorbid

levels.

25

First, epidemiologic studies have documented long-term cognitive

decline in patients with delirium, after controlling for relevant covariates.

Second, several causes of delirium may not be completely reversible,

particularly those resulting in neuronal injury and permanent cognitive

sequelae, such as prolonged hypoxia or hypoglycemia. Third,

Neuroimaging studies demonstrate regions of hypo perfusion in patients

with delirium. Thus, delirium may herald the onset of dementia in many

instances. Fourth, dementia with Lewy bodies, which includes fluctuating

cognition and visual hallucinations as core signs, illustrates the overlap of

delirium and dementia.( Voyer P, Cole MG, McCusker J, Belzile E.et

al. 2006;15(1):

Delirium can worsen the course of an underlying dementia, with

dramatic decline cognitive, result in more rapid progression of functional

losses and worse long-term outcomes.

Delirium might serve as an important model for research by

offering unique approach to advance the general understanding of

cognitive disorders and dementias.

26

Studying of delirium provides an important opportunity to clarify

the link between brain pathophysiology and behavioral manifestations,

which might hold broader implications for other cognitive and psychiatric

disorders. Newer strategies to increase acetylcholine activity in the brain

through the use of procholinergic agents and avoidance of highly

anticholinergic drugs and use of drugs to enhance cerebrovascular flow

(e.g., anti-inflammatory or antiplatelet agents),use of selective dopamine

antagonists that affect D1, D2, D3, and D4 receptors differently targeted

new therapeutic approaches in delirium may offer opportunities for early

intervention, preservation of cognitive-reserve capacity, and prevention

of permanent cognitive damage by which may potentially delay or abate

the ultimate development of dementia.

Physical Examination

Examination should elicit any signs of systemic illness, focal

neurological abnormalities, meningism, increased intracranial pressure,

extracranial cerebrovascular disease, or head trauma. In delirium, less

specific findings include an action or postural tremor of high frequency

(8-10 Hz), asterixis or brief lapses in tonic posture, especially at the wrist;

multifocal myoclonus or shocklikc jerks from diverse sites; choreiform

movements; dysarthria; and gait instability. agitation or psychomotor

retardation, apathy, waxy flexibility,catatonia, or carphologia ("lint-

27

picking" behavior). The presence of hyperactivity of the autonomic

nervous system may be life threatening because of possible dehydration,

electrolyte disturbances, or tachyarrhythmia’s

Laboratory Tests

Complete blood cell count; measurements of glucose, electrolytes,

blood urea nitrogen, creatinine, transaminase, and ammonia levels;

thyroid function tests; arterial blood gas studies; chest x-ray films;

electrocardiogram; urinalysis; and urine drug screening. computed

tomographic or magnetic resonance imaging scan of the brain, especially

if there are focal neurological findings or suspicions of increased

intracranial pressure, a space-occupying lesion, or head trauma. when the

cause is uncertain the lumbar puncture should be done

EEG changes Disorganization of the usual cerebral rhythms and

generalized slowing are the most common changes.

Both hypoactive and hyperactive subtypes of delirium have

similar EEG slowing, low-voltage fast activity is also present on

withdrawal from sedative drugs or alcohol EEG patterns from intracranial

causes of delirium include focal slowing, asymmetric delta activity, and

paroxysmal discharges (spikes, sharp waves, and spike-wave complexes).

28

Periodic complexes, such as triphasic waves, and periodic lateralizing

epileptiform discharges may help in the differential diagnosis.

Clinical

feature

Delirium Dementias Stroke with

Wernicke's

aphasia

Schizophren

ia

Course

Acute onset; hours,

days, or more

Insidious onset

Sudden onset;

chronic, stable

Insidious

more

Attention

Markedly impaired

attention

and arousal

months

or years;

progressive

Normal

Normal

Fluctuation

Prominent in

attention

arousal; disturbed

day-night

cycle

Normal early;

impairment

later

Absent

Absent

Perception

Misperceptions;

hallucinations,

usually visual,

fleeting; paramnes

Prominent

fluctuations

absent; lesser

disturbances in

day-night cycle

Normal

Hallucinatio

n

with present

Speech and

language

Abnormal clarity,

speed, and

coherence;

disjointed and

dysarthric;

misnaming;

Perceptual

abnormalities

much less

prominent*; Early

anomia; empty

speech;

Prominent

paraphasias and

neologisms;

empty speech;

abnormal

comprehension

Disorgantion

29

characteristic

dysgraphia

abnormal

comprehension

paramnesia

Other

cognition

Disorientation to

time, place;

recent memory and

visuospatial

abnormalities

Disorientation to

time, place;

multiple other

higher

cognitive deficits

No other

necessary

deficits

Behavior

Lethargy or

delirium;

nonsystematized

delusions;

emotional lability

Disinterested;

disengaged;

disinhibitcd;

delusions and

other psychiatric

symptoms

Paranoia

possibly

ensuing

Electroence

phalogy

Diffuse slowing;

low-voltage

fast activity; specific

pattern

Normal early; mild

slowing

later

Normal

30

TREATMENT

Nonpharmacologic Management

Nonpharmacologic interventions was the first line in the

management of a patient with suspected delirium.

Modifying the patient’s surroundings to maximize the safety and

calmness of the environment to provide reassurance and decrease fear and

agitation associated with delirium. Paper and pencil should be provided to

improve communication when the patient cannot respond verbally

because of intubation, adequate control of pain. Physical activity should

be initiated as soon as possible in order to minimize the adverse effects of

immobility (e.g., pressure sores), avoid deconditioning and enhance

orientation. Normal sleep–wake cycles can be promoted by the use of

daytime activity and environmental cues (such as windows and clocks)

family members can reassure the patient, provide reorientation, and

reduce anxiety and agitation

Pharmacologic Management

Benzodiazepines can increase both the risk and duration of

delirium, particularly in the elderly; the use of benzodiazepines should be

reserved for the management of agitation associated with sedative–

hypnotic withdrawal

31

Electroconvulsive Therapy

As a last resort for delirious patients with severe agitation who are

not responsive to pharmacotherapy given en bloc or daily for several

days,sometimes with multiple treatments per day ECT use in delirium

should be monitored closely as ECT can cause delirium on its own.

Treatment of Specific Etiologies of Delirium

Anticholinergic Intoxication

Anticholinergic poisoning almost always results in delirium and is

often present with physical agitation and visual hallucinations. Physical

signs of antimuscarinic action include widely dilated, poorly reactive

pupils; warm, dry skin; dry mouth; fever; tachycardia; elevated blood

pressure; constipation; and urinary retention and cardiac monitoring. Use

of cholinesterase inhibitors Physostigmine was effective

Wernicke Encephalopathy

Clinical feature manifest as nystagmus and ophthalmoplegia,

mental status changes, and unsteadiness of stance and gait, although this

triad is 16 percent of patients Wernicke encephalopathy is a medical

emergency, Thiamine should be initiate immediately, either

intravenously or intramuscularly, to ensure adequate absorption

32

Substance Intoxication

First step in treating substance abuse–related delirium is the

cessation of that substance. For benzodiazepine ingestions, treatment is

benzodiazepine receptor antagonist flumazenil. In ingestions of multiple

substance such as benzodiazepines and tricyclic antidepressants or

carbamazepine flumazenil may precipitate cardiac dysrhythmias or

seizures. Opiate intoxication can be treated with Reversal with naloxone

or naltrexone may be considered with adequate support and monitoring of

the cardiovascular and respiratory status. Naloxone acts through

competitive binding at opioid receptors, can reverse all the receptor-

mediated actions of opioids, and is indicated for patients who have

significant CNS or respiratory depression.

Substance Withdrawal

An evidence-based guideline from the American Society of

Addiction Medicine recommends benzodiazepines as a first-line agent for

the treatment of alcohol withdrawal

33

Treatment in Special Population

Antiparkinsonian agents are frequently implicated in causing a

delirium. Decreasing the dosage of the antiparkinsonian agent has to be

weighed against a worsening of motor symptoms clozapine is

recommended as it is the best studied of the second-generation

antipsychotic medications.

34

METHODOLOGY AND MATERIAL

This is a longitudinal follow up study, conducted at kilpauk

medical hospital Consecutive subjects who were diagnosed with delirium

were taken into the study. The standardized protocol treatment was

provided by the treating physician .Need for the study was explained and

informed consent was obtained in writing from the care givers.

Information was collected from care givers, staff nurse and from medical

records .Rating Scale was administered during the initial session .Follow

up was done using Delirium rating scale revised – 98 and Delirium

etiology check list was administered once in 2 days up to period of 1

month till the subject recovered, absconded or expired. The sample

consisted of 152 subjects (76 alcohol withdrawal vs 76 other medical

cause). The duration of the study was from march 2018 to September

2019 (18 month).

Inclusion

Meets DSM 5 criteria for delirium

Age >18years

consecutive delirium patients admitted in medical ward

35

All delirium subject admitted alcohol withdrawal was

considered to be a definite contributory etiological factor (with or

without other etiological factor)

Ethical approval

Ethical approval for the study was obtained from the Ethics

committee, Government Kilpauk Medical College, Chennai.

Tools used

• Semi structured socio demographic proforma (Name, age,

hospital no., gender, type of family)

• Kuppuswamy socioeconomic scale

Delirium rating scale revised – 98

Delirium etiology check list

Cognitive Test for Delirium [CTD]

Brief Psychiatric Rating Scale (BPRS)

Severity Of Alcohol Dependence Questionnaire (SADQ)

36

Kuppuswamy socioeconomic status scale

The modified Kuppuswamy scale is used to measure the

socioeconomic class. The instrument was structured by Kuppuswamy in

1976. it comprises several scores such as income per month of the

family, occupation of the family head along with , education which

gives a score between 3 -29. According to instrument the study

population is classified into five socioeconomic classes which includes

1. Upper.

2. Upper middle.

3. Lower middle.

4. Upper lower.

5. Lower.

The score for education is between 1 to 7, occupation between 1 to

10 and monthly income between 1 to 12. The scale was repeatedly

modified because of the price index changes as it that affects the validity

of the monthly income subset in the instrument (Patro BK et al. 2012.,

Sharma et al .2014., Kumar BR et al. 2012,, Saleem Sheikh e

37

Cognitive Test for Delirium

It is a neuropsychological function test that relay on visual

abilities and can be administered to individuals including those who are

cannot speak or intubated. It is initially structured for ICU patients who

are severely ill. The instrument uses non verbal responses such as raising

hand, nodding head, pointing by the patients. It measures the 5

neuropsychological domains

1. Orientation.

2. Attention.

3. Memory.

4. Comprehension.

5. Vigilance

It is scored between 0-30, the higher scores represents better

cognitive function. A cut off of <19 is used to differentiate delirium from

other disorders, it is also used as a unidimensional and continuous

measure of cognition in acute confusional state. It can distinguish reliably

between depression, schizophrenia and dementia (Hart et al, 1996).

38

Revised Delirium Rating Scale (DRS-R-98)

This scale is most widely used instrument for measure the severity

of symptom in acute confusional state; it can be used both as an

assessment and a diagnostic tool. It consists of3 diagnostic items

(physical disorder, fluctuation of symptoms, temporal onset of symptoms)

and 13 severity items and it covers most of the symptoms. The individual

items severity is scored between 0 to 3 points. The total DRS-R98

severity scores between from 0-39 with severe delirious state indicating

higher scores. Diagnosis of delirium is made with a cut-off score >15.

The whole scale is used initially for indentifying different differential

diagnosis by capturing specific features of acute confusional state like

acute onset of symptom severity and fluctuating nature. The scale is used

to score symptoms from variable periods and can be used as a follow up

instrument. Inter-rater reliability is high, specificity ,validity and

sensitivity form differentiating acute confusional state from other

neuropsychiatric disorders such as schizophrenia, depression, and

dementia is high(Trzepacz et al, 2001).

39

Etiological assessment

The Delirium Aetiology Rating Checklist (DEC), assesses the

different aetiologies of acute confusional state by scoring 12 contributing

causes. Each causal category is scored between a five-point scales

ranging from

0. Ruled out

1, present but apparently not contributory

2. Present and possibly contributory

3. Likely cause

4. Definite cause

It allows for two or more concomitant causes for Acute

confusional state. (Meagher and Trzepacz, 2009)

Severity of alcohol dependence questionnaire (SADQ)

The SADQ is a scale for measuring alcohol dependence severity.

It was categories as the level of dependency to alcohol in based on score

of 30+ as severe dependency and between scores of 16-30 as moderate

dependency and of less than 16 taken as mild dependency. Questions

cover following Onset of withdrawal symptoms, Frequency of alcohol

40

consumption, Affective withdrawal symptoms, Physical withdrawal

symptoms, Relief drinking

Brief Psychiatric Rating Scale

The Brief Psychiatric Rating Scale assesses psychopathology

(Hafkenscheid, 1991).an 18 items scale is used since 1967 as the standard

version. The five factor scores including, tension-excitement, withdrawal-

retardation, thinking disturbance, hostile suspiciousness, and anxious

depression, other than psychotic phenomology can also be scored. Due to

its flexibility and easy adaptability it is used widely in research and

clinical settings. (Van der Does (1993).Overall, J.E., & Hafkenscheid, A.

(1991) Gorham, D.R. (1962)

41

STATISTICAL ANALYSIS

Descriptive data.

• Frequency,

• Percentage,

• Mean,

• Standard deviation calculated.

Comparison between the groups was done by using- SPSS-14

• 2‐tailed Student’s t,

• chi‐square,

• Fisher’s exact tests.

Sample size-76 vs 76

• Confident index -95%

• Power-75%

42

• Sample size calculated using previous study Sandeep Grover

et el Delusion Prevalence,–general medical condition (27.8%) & Alcohol

withdrawal delirium (48.2%)[p=.001]

Calculated and derived value a sample size of =76 general medical

condition vs 76 Alcohol withdrawal delirium

43

RESULT

A total of 152 subjects were taken for this study in which 76

subjects were diagnosed to have alcohol withdrawal delirium and 76

subjects were diagnosed having other medical cause of delirium

The subjects were enrolled from Psychiatric Ward 35.5% (54),

Medicine Ward 31.6% (48), Intensive care unit 19.1% (29), Surgery

Ward 8.6%(13), Orthopedic Ward 2.6%(4), obstetrics and gynecology

1.3%(2), and causality 1.3%(2).

Diagram 1 frequency of subject obtained

.

Percentage

Psychiatric Ward 35.5%

Medicine Ward 31.6%

Intensive care unit 19.1%

Surgery Ward 8.6%

Orthopedic Ward 2.6%

obstetrics and gynecology1.3%

causality1.3%

44

Table : Total socio demographic data

Age 16-30 years (23) 15.1%

31-45 years (34) 22.4%

46-60 years (56) 36.8%

Above 60 years (39) 25.7%

Gender Male (131) 86.2%

Female (21) 13.8%

Socio-Economic Status Upper (2)

Upper Middle (7)

Lower Middle (72)

Upper Lower (57)

Lower (14)

Type of Family Nuclear (104)

68.4%

Joint (45) 29.6%

Extended (3) 2.0%

H/o of Concurrent

Substance Use

SLT (32)

21.1%

Cannabis (6)

3.9%

Nicotine (57)

45

37.5%

Previous h/o of Seizures (26)

17.1%

Previous h/o of Head

Injury

(1)

.7%

Previous h/o Delirium

Tremens

(20)

13.2%

Family h/o Psychiatric

Illness

(8)

5.3%

Family h/o Alcohol Use

Disorder

(30)

19.7%

The mean age of participants was 49.The male to female ratio

was86:14. The most of the subjects are from lower middle socioeconomic

state (47.4%) according to Kuppuswamy socio demographic score,

followed by Upper Lower socioeconomic states 37.5%, Lower

socioeconomic states 9.2% Upper Middle socioeconomic states 4.6%

Upper socioeconomic states 1.3%.Type of Family of subjects were

nuclear 68.4%, Joint29.6% and Extended2.0%.

Diagram2

The

smoking

smoking 3

The

history of

injury is

in5.3% a

19.7%.Th

In

delirium

delirium a

male: fem

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%

2 Frequen

e predom

37.5% fo

3.9%.

e past his

f seizure e

present in

and a fam

he Co mor

comparis

and delir

all 76 subj

male ratio i

%%%%%%%%%%%

Upp

1.3

ncy of soc

minant sub

ollowed b

story of d

episode w

n 7%. Fam

mily histo

rbidity of M

son betw

rium due

jects were

is 72:28.

per UpMid

30%4

46

cio demog

bstance u

by smokel

delirium a

was presen

mily histo

ory of Al

Medical Il

ween two

to medic

e male and

per ddle

LoMi

.60%

4

graphic sc

use among

less tobac

mong sub

nt in 17.1%

ory of Psy

cohol Us

llness is pr

groups

cal cause

d in deliri

ower iddle

UL

47.40%

core

g subject

cco 21.1%

bjects was

%. A past

ychiatric I

e Disorde

resent in 4

i.e. alco

s, in alco

ium due to

Upper Lower

37.50%

ts was N

% and Ca

s 13.2%.

t history o

Illness is p

er is pres

49.3%

ohol with

ohol with

o medical

Lower

9.20%

Nicotine

annabis

A past

of head

present

sent in

hdrawal

hdrawal

causes

47

Table :Various blood parameter

Parameter Minimum Maximum Mean±SD

Hb 2.0 17.0 11.334±3.0281

MCV 67.0 99.0 82.012±6.7511

MCHC 29.1 39.0 34.822±2.2075

SGOT 11 530 67.20±74.747

SGPT 9 484 59.26±78.917

S.Bilirubin .50 22.00 2.0409±3.26431

RBS 52 400 147.97±59.004

Blood urea 11 248 39.31±40.966

S.Creatinine .4 6.8 1.393±1.3116

Na 110 152 135.62±9.515

K 2.0 5.5 4.018±0.6342

The various blood parameterswere examined such as complete

blood count, Liver function test, serum urea, creatine and electrolytes

48

Table: Longitudinal analysis using Drs-98 scale, measured 48 hours

apart

Parameters DRS-1 DRS-2 DRS-3

Mean±SD Mean±SD Mean±SD

Sleep wake cycle

disturbance

2.75±0.434 1.26±0.750 0.46±0.562

Perceptual Disturbance 1.19±1.270 0.23±0.521 0.06±0.238

Delusions .51±1.042 0.18±0.624 0.09±0.445

Liability of affect 2.05±0.961 0.75±0.721 0.21±0.440

Language 1.36±1.216 0.40±0.721 0.05±0.240

Thought process

abnormalities

0.61±0.971 0.22±0.542 0.09±0.333

Motor agitation 1.76±1.223 0.66±0.745 0.14±0.383

Motor retardation 0.89±1.213 0.32±0.637 0.09±0.421

Orientation 2.13±0.995 0.70±0.789 0.13±0.376

Attention 2.03±1.023 0.51±0.651 0.08±0.316

Short-term memory 1.52±1.104 0.46±0.650 0.07±0.274

Long-term memory 0.99±1.058 0.30±0.562 0.05±0.300

Visuospatial ability 1.45±1.167 0.39±0.710 0.07±0.307

49

SURFACE Diagram frequency of DRS -98

00.5

11.5

22.5

3

Sleep-wake cycle disturbance Perceptual

DisturbanceDelusions

Lability of affect

Language

Thought process abnormalities

Motor agitationMotor retardation

OrientationAttention

Short-term memory

Long-term memory

Visuospatial ability

Temporal onset of symptoms

Fluctuation of symptom severity

Physical disorder

DRS-1

DRS-2

DRS-3

50

Total frequency of drs -98 items of severity and moderate or severe

severity

DRS-R98 Items Present at any severity %

Moderate or severe severity %

Neuropsychiatric and Behavioural:

1. Sleep-wake cycle disturbance

100 100

2. Perceptual disturbances and hallucinations

50.7 45.4

3. Delusions 21.7 19.1 4. Liabilityof affect 87.5 81.5 5. Language 63.5 50 6. Thought process abnormalities

32.9 20.4

7. Motor agitation 72.4 63.8 8. Motor retardation 39.5 33.6 Cognitive: 9. Orientation 86.5 82.9 10. Attention 87.4 76.1 11. Short-term memory 75.7 51.4 12. Long-term memory 54.6 34.2 13.Visuospatial ability 69.1 51.2

The frequency of non-cognitive symptoms among subjects were

sleep disturbance 100%, Lability of affect 87.5% and motoric.

Disturbance (hyperactive 72.4 and hypoactive39.5). Language and

thought process abnormalities were present in .over half of the subjects

but were less. common than cognitive .symptoms.. Cognitive symptoms

seen among subjects were Attention difficulty 87.4%, disorientation

86.5% and psychotic symptoms which include Perceptual disturbances

and hallucinations 50.7%and Delusions 21.7%.

51

Table Frequency of cognitive test for delirium

Total CTD Score

.5-6

Score.

3-4

Score.

1-2

Score

0

Mean .score

(range 0-6)

Orientation. 0 50 102 0 2.19±0.770

Attention .span 0 19 133 0 1.81±0.638

Memory 0 16 136 0 1.82±0.603

Comprehension. 0 30 120 2 1.95±0.758

Vigilance. 0 22 128 2 1.80±0.694

Frequency (%) of different .severity levels of cognitive. dysfunction

Orientation2.19±0.770 .mean ± SD Vigilance 1.80±0.694.item scores

assessed .with the CTD (n=152) where .lower scores indicate poorer

.performance

0

50

0

0

102

0

Sco

0

19

133

0

ore 5-6

52

0

16

136

Score 3-4

0

3

6

0

Score 1-

0

120

2

2 Score

0

22

128

2

e 0

53

Table: Mean of CTD, DRS R-98, SADQ and BPRS

Variables Minimum Maximum Mean

Std.

Deviation

SADQ-C 0 39 27.03 ±4.511

DRS - 1 15 36 24.10 ±5.392

DRS - 2 0 21 7.82 ±5.491

DRS - 3 0 15 1.79 ±2.708

CTD 4 13 9.38 ±2.156

BPRS 18 30 20.53 ±1.922

The mean score of SADQ-C 27.03±4.511and DRS – 1 is

24.10±5.392and DRS -2 is 7.8 ±5.491and DRS – 3 1.79 ±2.The

cognitive test for delirium was 9.38±2.1and Brief psychiatric rating scale

score was 20.53±1.922

54

Table Correlation between cognitive test for Delirium and Delirium

rating scale -98

DRS

CTD Orientation.

Attention

.span Memory Comprehension. Vigilance

Sleep-wake. cycle

disturbance

-0.015

(0.856)

-0.006

(0.942)

0.076

(0.353

-0.096

(0.242)

0.027

(0.737)

Perceptual .

Disturbance

0.145

(0.074)

0.086

(0.292)

0.193*

(0.017

0.023

(0.779)

0.180*

(0.027)

Delusions. 0.348**

(0.000)

-0.071

(0.385)

0.120

(0.141

0.374**

(0.000)

0.127

(0.118)

Lability of . affect -0.112

(0.169)

0.189*

(0.020)

0.097

(0.235

-0.069

(0.396)

-0.063

(0.439)

Language. -0.067

(0.411)

-0.167*

(0.040)

-0.162*

(0.047

-0.082

(0.313)

-0.336**

(0.000)

Thought .process

abnormalities

0.057

(0.484)

0.027

(0.739)

0.113

(0.167

0.092

(0.259)

-0.002

(0.977)

Motor .agitation 0.092

(0.260)

0.076

(0.353)

0.047

(0.569

009

(0.910)

0.050

(0.538)

Motor .retardation -0.227**

(0.005)

-0.077

(0.343)

-0.181*

(0.026

-0.113

(0.164)

-0.222**

(0.006)

55

Orientation -0.293**

(0.000)

0.196*

(0.015)

-0.059

(0.472

-0.124

(0.129)

-0.230**

(0.004)

Attention. 0.078

(0.341)

-0.002

(0.977)

-0.046

(0.575

-0.016

(0.849)

-0.030

(0.716)

Short-term

.memory

-0.032

(0.698)

0.057

(0.485)

-0.174*

(0.032

-0.050

(0.538)

-0.034

(0.681)

Long-term

memory.

-.0291**

(0.000)

-0.002

(0.982)

-0.158

(0.052

0.041

(0.617)

-0.119

(0.144)

Visuospatial

.ability

-0.022

(0.789)

-0.027

(0.742)

-0.023

(0.776

-0.096

(0.237)

-0.238**

(0.003)

While comparing the cognitive test for delirium (CTD) with

delirium rating scale (DRS-98) on the cognitive and non cognitive

symptom profile

1. There was significant positive correlation between orientation and

Delusions (0.348**) where as Motor retardation (-0.227**) and Long-

term memory (-.0291**) negative correlated with orientation

2. Attention span had significant positive correlation with Orientation

(0.196*) , negatively correlated with Language (-0.167*) .

56

3. Positive correlation between Memory and perceptual Disturbance

(0.193*) was present. Short-term memory (-0.174*) and Motor

retardation ( 0.181*) negatively correlated.

4. Comprehension had significant positive correlated Delusions

(0.374**)

5. Vigilance had significant positive correlation with Perceptual

Disturbance (0.180*) and negatively correlated with Language(-

0.336** ) Visuospatial ability (-0.238**), Orientation (-0.230**) and

Motor retardation(-0.222**).

57

Table duration of delirium, hospital ,treatment and outcome

DAYS TOTAL

SUBJECT

Total duration of delirium 1 25

2 58

3 34

4 19

>5 16

Total duration of Hospital <5 77

6-10 43

11-45 32

TRATMENT GIVEN Benzodiazepam Usage (82 ) 56.5%

Antipsychotic Usage (22) 14.4%

Outcome Recovered 137 90.2%

Death 11 7.2%

Absconded 4 2.6%

The duration of hospital stay hospital stay is 8 days and in half of

the subjects the delirium resolved within 2 days (83). Treatment given is

benzodiazepines 56.5%, antipsychotic 14.4%.

58

The outcome of the delirium in subjects is Recovered 90.2%

Death7.2% Absconded2.6%.

outcome of the delirium

Recovered 90.2%

Death7.2%

Absconded2.6%

59

Table: Medical cause of delirium

Causes Possible Probable

Drug. intoxication 0 0

Drug. withdrawal (5)6.5% 0

Metabolic/.endocrine (19)25% 41 (53.9%)

Traumatic .brain injury 0 0

Seizures (4)5.2% (8) 10.5%

Infection. intracranial (8)19.8% (2) 2.6%

Infection. (systemic) 6 (9 )11.8%

Neoplasm. intracranial 0 (1) 1.3%

Neoplasm systemic (1) 1.3% 0

Cerebrovascular. (19)25% (3) 3.9%

Organ .insufficiency (6)7.8% 0

Other central .nervous system 0 (2 )2.6%

Others. (2)2.6% 0

According to delirium check list, cause of medical delirium (76)

with most definite and likely cause (>3) were Metabolic/endocrine (41)

53.9%, Infection (systemic) 11.8%, Seizures10.5%, Cerebrovascular

3.9%, Infection intracranial and Other central nervous system is2.6%. In

possible contributory and present and not contributory cause (<2),

Metabolic

insufficien

causes2.6

Subtypes

The

who score

those who

and those

is subtype

0

5

10

15

20

25

30

35

40

45

c/endocrin

ncy 7.8%

6% and sys

s of medic

e motor a

e positive

o score po

e who are

ed as mixe

ne cause i

%, Drug

stemic Ne

cal cause o

actives has

on motor

ositive on

scored po

ed type

60

is 25%, In

withdraw

eoplasm 1.

of deliriu

s been sub

r agitation

n motor re

ositive in b

nfection i

wal 6.5%

.3%,

m

btyped by

issubtype

etardation

both moto

intracrania

%, Seizur

y using drs

ed as hype

is subtye

r agitation

al 19.8%,

res5.2%,

s-98 scale

eractive ty

ed as hypo

n and retar

P

P

Organ

Others

e, those

ype and

oactive

rdation

Possible

Probable

61

Table Frequency of subtype of motor agitation or retardation

Causes.

Subtypes

Hypoactive Mixed Hyperactive

Percent Percent Percent

Drug. withdrawal (6) 7.9% (1) 1.3% (4) 5.3%

Metabolic/.Endocrine (3) 3.9% (13) 17.1% (37) 48.7%

Seizures. 0 (2) 2.6% (4) 5.3%

Infection

.(Intracranial) (3) 3.9% (8) 10.5% (2) 2.6%

Infection .(Systemic) (2) 2.6% (6) 7.9% (9) 11.8%

Neoplasm

.(Intracranial) 0 0 (1) 1.3%

Neoplasm.

(systemic) 0 (1) 1.3% 0

Cerebrovascular. 0 (17) 22.4% (3) 3.9%

Organ. Insufficiency (10) 13.2% (6) 7.9% 0

Other (Central

.Nervous System) 0 0 (2) 2.6%

Other 0 2 2.6% 0

62

The hyper active delirium is seen more in delirium due to

Metabolic/Endocrine causes(48.7%) and mixed type is seen in delirium

due to Cerebrovascular causes (22.4%) and hypoactive delirium is seen in

delirium due to Organ Insufficiency (13.2%)

63

Table of Descriptive data of alcohol withdrawal delirium

Delirium Cause

Alcohol withdrawal Delirium N (76)

Age of onset of alcohol use 19.47±5.541

Duration of Dependence Pattern 16.97±8.534

Amount of Alcohol Intake per Day 478.95±167.933

Family h/o Psychiatric Illness 8 (10.5%)

Family h/o Alcohol Use Disorder 28 (36.8%)

Co morbidity Medical Illness 14 (18.2%)

Concurrent Substance Use-

SMOKELESS TOBACCO 30(39.4%)

Cannabis 2(2.6%)

Nicotine 38 (50%)

No Other Substance Use 6 (7.8%)

SADQ 27.03 ±4.511

The mean is age of onset of alcohol dependence is 19.47±5.541,

Duration of alcohol use in Dependence Pattern is 16.97±8.534 and mean

amount of Alcohol Intake per ml per Day 478.95±167.933.the mean

severity of alcohol dependence questionere (SADQ) is 27.03 ±4.511

64

Table of Compare the medical and alcohol withdrawal delirium

Age and Delirium Cause

Age

Delirium Cause

Chi-

Square

Value

P-ValueAlcohol withdrawal

Delirium

N 76

Medical

Illness

Delirium

N 76

16-30 years 14 9

16.108 <0.001*31-45 years 24 10

46-60 years 28 28

Above 60 years 10 29

On comparing the age between medical illness delirium and

alcohol with drawal Delirium, most subjects having medical illness

delirium are more than 60 years of age. This have been shown statistical

significance when compared to the alcohol withdrawal delirium (p value

0.01)

65

0

5

10

15

20

25

30

35

16-30 years 31-45 years 46-60 years Above 60 years

Alcohol withdrawal Delirium

Medical Illness Delirium

66

Table : Comparison of demographic details between alcohol

withdrawal and medical illness delirium

Variable

Compare

Chi-Square

Value P-Value

Alcohol

withdrawal

Delirium

N 76

Medical

Illness

Delirium

N 76

Previous h/o

Seizures

22

28.9%

4

5.2% 15.033a ns

Previous h/o Head

Injury

0 1 1.007 0.316(ns)

Previous h/o

Delirium

18

23.6%

2

2.6% 14.739 0.001**

Family h/o

Alcohol Use

Disorder

28

36.8%

2

2.6% 28.074 0.001**

Family h/o

Psychiatric Illness

8

10.5%

0 8.444 0.006**

Comorbidity

Medical Illness

14

61 58.142 0.001**

67

On comparing the past history of seizure, there were no significant

differences between alcohol withdrawal delirium and medical illness

delirium. The Family history of Psychiatric Illness in Alcohol withdrawal

Delirium (10.5%)is statistically significant withChi-Square Value 8.444 p

value is < 0.006**. In Medical illness delirium Comorbid Medical

Illness(such as hypertension, diabetes etc.) were statically significant with

Chi-Square value of58.142 and p value of 0.001**.

Surface diagram depicting mean difference between alcohol

withdrawal Delirium and other cause of medical delirium

On Comparing the clinical profile differences among groups,

it was found that subjects with alcohol withdrawal Delirium had more

psychotic symptomatic such Perceptual Disturbance 1.45, Delusions

.89and motor disturbances - Motor agitation 2.22

.00

.501.001.502.002.503.00

Sleep-…Perceptual …

Delusions

Lability of …

Language

Thought …

Motor …Motor …

OrientationAttention

Short-…

Long-term …

Visuospati…

Temporal …

Fluctuatio…Physical …

DRS-1 Medical Illness DeliriumDRS-3 Alcohol withdrawal Delirium DRS-2Medical Illness DeliriumDRS-3 Alcohol withdrawal Delirium

68

Table: comparison of frequency of symptom profile and severity

between groups

Delirium rating scale

R 98

Present at any .severity

%

Moderate .or severe

severity %

Alcohol

withdrawal.

Delirium

N 76

Medical

Illness

.Delirium

N 76

Alcohol

withdrawal

.Delirium

N 76

Medical

Illness

Delirium

N 76

Neuropsychiatric. and

Behavioural:

1. Sleep-wake. cycle

disturbance

100 100 100 100

2. Perceptual.

disturbances and

hallucinations

63.2 38.2 55.2 35.6

3. Delusions 36.3 5.3 33.7 4

4. Lability .of affect 84.2 90.8 78.9 84.2

5. Language 50 76.3 36.2 63.1

6. Thought .process

abnormalities

36.2 28.9 23.4 17.1

69

7. Motor. agitation 88.1 56.6 84.2 43.2

8. Motor. retardation 18.4 60.5 10.5 56.6

Cognitive:

9. Orientation. 84.2 89.5 78.9 86.9

10. Attention 84.2 90.7 68.4 80

11. Short-term .memory 73.7 77.6 44.8 61.8

12. Long-term. memory 52.6 56.6 28.9 39.5

13.Visuospatial abil.ity 68.4 69.7 50 52.6

The Alcohol withdrawal Delirium and Medical Illness Delirium

both have common features like Sleep-wake cycle disturbance. In

Alcohol withdrawal Delirium most frequent symptom is Motor agitation

88.1%and Cognitivedisturbances such as Attention disturbances and

disorientation is 84.2%. In Medical Illness Delirium the most frequent

symptomsisAttention disturbances 90.7%, Lability of affect 90.8% and

Motor retardation 60.5%.

70

Duration of delirium comparison between both groups

Variables Alcohol

withdrawa

l Delirium

Medical

Illness

Delirium

Chi-Square

Value

P-Value

total duration of

delirium days

<3 64 53 4.4913

<0.0340

>4 12 23

71

Independent Samples Test between Delirium Cause and Total duration of delirium

Total

duration

of delirium

Delirium Cause

t-value P-ValueAlcohol withdrawal

Delirium

Medical

Illness

Delirium

2.45±1.171 3.22±3.408 1.878 .062

This table compares between the total duration of delirium

between Alcohol withdrawal and Medical Illness groups. In Alcohol

Withdrawal Delirium (84.2%) and Medical Illness Delirium (69%)

recovery is seen in 3 days. Delirium persisting for more than 3days in

Alcohol withdrawal group is about 15.8%and Medical Illness group is

about 30.3%, there no statistical significance among two groups

regarding the duration of delirium.

72

Table: Treatment and outcome of delirium between two groups

94.7% of subjects with Alcohol Withdrawal Delirium recovered

and 5.3%Absconded. In Medical Illness Delirium mortality was seen in

14.5% and recovery is seen in 85.5% with Chi-Square Value of

16.4633and p value of<0.001**. In treatment subjects having Alcohol

withdrawal Delirium mostly received benzodiazepines(97%) and

Antipsychotics (28%).In Medical Illness Delirium benzodiazepines was

used in 7.8% of subjects and Antipsychotics was used in 14.4% of

subjects .

Variables Alcohol withdraw

al Delirium

Medical Illness

Delirium

Chi-Square Value

P-Value

Outcome Recovered 72 65 16.463 <0.001* Death 0 11 Absconded 4 0

Treatment Benzodiazepines Usage

74 6

122.022 <0.001

Antipsychotic Usage

22 11 4.683 0.048

73

Independent Samples Test between Delirium Cause and Total

duration of Hospital

Total

duration of

Hospital

Delirium Cause

t-value P-ValueAlcohol withdrawal

Delirium

Medical

Illness

Delirium

5.50±2.517 11.37±8.230 5.945 <0.001**

Comparing the total duration of mean hospital stay between the

two groups using t –test, hospital stay in medical illness delirium is

11.37±8.230 days and Alcohol withdrawal Delirium is 5.50±2.517 days ,

longer hospital stay is seen with statistical significance (p value

<0.001**) in medical illness delirium.

74

DISCUSSION

The delirium is considered as a neuropsychiatric syndrome that

results from an underlying medical condition or substance

intoxication/withdrawal. This study was one of the few attempts at

examining various descriptive data of delirium and phenomenology of

delirium with both cross sectional and Longitudinal scales such as drs-

98. DRS-98 examine subjects 48 hours apart for three consecutive times

and measure the cognitive defect. With cognitive delirium rating scale

cognitive deficit is measured and compared with DRS-98for

phenomenological differences. Another interesting thing is that very few

studies have looked into the relation between orcompared Alcohol

Withdrawal Delirium and other Medical Illness Delirium as groups.

The mean age of participant in this study is 49, 25.7% of subjects

in this study are above 60, in similar studies (done by Sandeep Grover et

al 2013) the mean age is 44.5(SD: 13.05; range 22–85 years) and subjects

who are above 60years of age is 8%.Subjects who are above 60 years are

found to have episodes of delirium due to medical illness which is

significantly greater than those who have alcohol withdrawal delirium ,

this may be attributed to increased age which is a risk factor as increased

age increases cognitive deficit which predisposes elderly population to

75

develop delirium, this finding is also in line with an another study

Maclullich et al, 2009. Most subjects who have Alcohol withdrawal

Delirium belongs to an younger age group population as substance use is

greater among the younger population.

The male to female ratio is 86: 14. This large difference is noted

as all of the subjects from alcohol withdrawal Delirium (76) are male.

This study is conducted in urban population at a tertiary care center and

majority of subjects belonged to lower middle socioeconomic states

47.4%

The various risk factors were assessed such as history of delirium,

co morbidity illness, seizure, concurrent substance use, family history of

alcohol and psychiatric illness. In subjects who have Alcohol Withdrawal

Delirium, past history of delirium has shown significant differences when

compared to medical illness delirium. Past history of delirium was

considered as a risk factor to develop delirium as delirium cause

cognitive defects which predisposes further multiple episodes in future (

grover et al 2013). The co morbid medical illnesses(such as hypertension,

Diabetes etc) are high and showedsignificantly high correlation to

Medical Illness delirium,which is considered as a predisposer to

Delirium.AFamily history of psychiatric illness in Alcohol withdrawal

76

Delirium was significant and similar finding is seen in Thiercelin N,

Rabiahevallier Z Rusch E ,Et Al 2012.

A comparison of frequency of various symptoms between Alcohol

withdrawal Delirium and Medical Illness delirium was assessed byDRS –

r 98.Alcohol withdrawal Delirium had high prevalence of Perceptual

disturbances and hallucinations, Delusions and Thought process

abnormalities and low prevalence of Motor retardation , Language

disturbances. This finding was similar to Grover et al. However,

frequency of core symptom such as Attention and Orientation was no

different in the both groups of delirium. Hence the core symptoms of

delirium are seen in subject with delirium due to any cause, underlying

etiology may contribute to subtle differences in the symptomatology.

In the delirium etiological check list, the most common factors

apart from alcohol withdrawal are metabolic /endocrine abnormalities

53.9%, followed by Cerebrovascular25%, infection systemic11.8%,

similar finding is seen in previous studies Grover et al. In medical illness

delirium the frequency of pattern motor subtype has been assessed. The

hyperactive type was 48% and hypoactive type was 13.7% and mixed

type was 22.4% which show no statistical significance, to earlier studies

done. The morality rate in this study is 7.2% when compared to gover et

77

al 2012 this value is low, this may be because no mortality was noted in

alcohol withdrawal delirium in our study.

The delirium rating score -98 was used in 3 consecutive session

every two days and the finding suggests early delirium usually presents as

psychomotor disturbances and sleep-wake cycle disturbances, a similar

finding was seen in Fann et al, 2005. Sleep disturbances, emotional

labiality, and orientation difficulties are most persistent symptoms and

these findings were similar with that of Levkoff et al, 1994; McCusker et

al, 2003.When compared between groups the medical illness delirium had

statically significant difference in language symptoms.

Delirium symptoms are categorized into ‘core’ features which

includes disturbances of orientation, memory, attention, sleep-wake

cycle, thought processes, language) and ‘associated’ features that varies

in presentation includes different motoric profiles ,affective disturbances,

psychotic symptoms) (APA, 1999; Trzepacz, 1999). The evaluation of

equivalent cognitive items on the CTD and DRS-R98 have high

correlations (inversely as expected) in spite of one being a cognitive test

measuring current status and the other being a symptom rating scale

assessing behavioral and cognitive symptoms in a 48-hour period.There

was significant positive correlation between cognitive domain (such as

78

orientation, Memory, Comprehension and Vigilance )with that of

psychotic symptoms ( such as Perceptual Disturbance, Delusions) ,it may

be because cognitiveimpairmentcauses misperceptions or

misunderstanding of the external environment or individual’s

susceptibility to psychotic symptoms or as a part of mood disturbances

Francis, 1992.Various studies comparing psychotic symptoms of Acute

confusional state with that of schizophrenia found that in acute

confusional state hallucinations are visual more than auditory and formal

thought disorders which are frequently found are illogicality and poverty

of thinking and thought content disturbances involve themes of

immediate surroundings and circumstances (Cutting, 1987). The

visuospatial ability scores were correlated with disorientation, this may be

reflecting the role that is shared by representative posterior parietal cortex

in both orientation and visuospatial functions (Trzepacz 1999).

Themean morality rate in this study is12.7%, whereas comparing

the mortality rate of Alcohol Withdrawal Delirium and Medical Illness

delirium, the mortality rate in medical illness delirium was 14.4%,this

finding was similar to gover et al 2013. Hypoactive delirium is reported

to have a Poorer Prognosis Lam et al, 2003; Kelly et al, 2001; Olofsson et

al, 1996.The mean duration of delirium was 2 days similar finding was

found in earlier studies gover et al 2013.Alcohol withdrawal group had a

79

mean duration of delirium of2.45±1.171and most of them recovered in

2days as similar to earlier study conducted in India gover et al 2013. On

comparing the both groups there were no significance in total duration of

delirium. The mean total duration of hospital stay is 8 days. There was

significant difference in mean total duration of hospital stay in Medical

Illness group (11.37±8.230) than the Alcohol withdrawal Delirium group

(5.50±2.517) similar finding seen in and reluizmoschetta et al

80

CONCLUSION

In this study, the proportion of medical cause of delirium was

more in the elderly population. No significant differences were found

between the two groups in terms of type of family, socioeconomic status

and gender.

Medical illness delirium was higher than alcohol withdrawal

delirium with increasing age. Statistical significance was found for

subjects with previous history of delirium in alcohol withdrawal delirium

group than in medical illness delirium group. No significant difference

was found not in regards to past history of head injury and past history of

seizures. Alcohol withdrawal delirium group had significant higher

proportion of family history of psychiatric illness compared to the control

group.

In medical illness delirium group the delirium etiology check list

showed metabolic / endocrine abnormalities as the most common cause

and the motor subtype of most of them were hyperactive. When delirium

symptoms severity was compared between the two groups with the DRS

R-98 high prevalence of psychotic symptoms was seen in alcohol

withdrawal delirium and there was no difference in core feature of

delirium. In the longitudinal follow up of every two between two groups

81

with DRS R-98, initial 48 hours is characterized by behavior symptoms

(psychomotor disturbances and disrupted sleep wake cycle) and core

symptoms (attention impairment, orientation difficulties, emotional

labiality). On comparison of cognitive test of delirium and delirium rating

scale, there was positive correlation with cognitive domain and psychotic

domain. The mean duration of delirium was 3 days. The medical illness

delirium group had significant higher mortality rate compared to alcohol

withdrawal delirium. The total duration of hospital stay was found to be

more for medical illness delirium. The medical illness subjects belonged

to a older age group and had poorer prognosis when compared to alcohol

withdrawal group which had a younger population with better recovery.

82

LIMITATION

• Since the study was a hospital based inpatient study, the study

population may not represent less severe cases. Hence less severe

cases could be missed out.

• The investigator was not blinded with diagnosis of the patient and

hence the chance of observer error has to be considered.

• The DRS R98 scale was used in the study population only for a

limited period

BIBLIOGRAPHY

1. A study of symptom profile and clinical subtypes of delirium, David

Meagher MD, DPM, MRCPsych, MSc (Neuroscience), MHSc

(Clinical Teaching) University of Limerick Medical School and

Limerick Mental Health Services

2. Management of Alcohol Withdrawal Delirium ichael F. Mayo-Smith,

MD, MPH; Lee H. Beecher, MD; Timothy L. Fischer, DO; David A.

Gorelick, MD, PhD; Jeanette L. Guillaume, MA; Arnold Hill, MD;

Gail Jara, BA; Chris Kasser, MD; John Melbourne,MD;

3. Symptom Profile and Outcome of Delirium Associated with Alcohol

Withdrawal Syndrome: A Study from India Sandeep Grover, MD,

Akhilesh Sharma, MD, Natasha Kate, MD, Surendra K. Mattoo, MD,

Debasish Basu, MD, Subho Chakrabarti, MD, Savita Malhotra, MD,

Ajit Avasthi, MD

4. The delirium subtypes: A review of prevalence, phenomenology,

pathophysiology, and treatment response DANIELE STAGNO,

M.D.,1 CHRISTOPHER GIBSON, PH.D.,2 AND WILLIAM

BREITBART, M.D.2 1Service de Psychiatrie de Liaison, CHUV-CH-

1011 Lausanne, Switzerland 2Department of Psychiatry and

Behavioral Sciences, Memorial Sloan-Kettering Cancer Center,New

York, New York

5. Delirium: Phenomenologic and Etiologic Subtypes stopher A. Ross,

M.D., Ph.D., Carol E. Peyser, M.D.,ra Shapiro, M.D., and Marshal E

Folstein, M.D. Department of Psychiatry The Johns Hopkins

University School of Medicine Baltimore, Maryland, U.S.A.

6. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the

management of pain, agitation, and delirium in adult patients in the

intensive care unit. Crit Care Med. 2013;41

7. Bellelli G, Frisoni GB, Turco R, Lucchi E, Magnifico F. Delirium

superimposed on dementia predicts 12-month survival in elderly

patients discharged from a postacute rehabilitation facility. J Gerontol

A Biol Sci Med Sci. 2007;62

8. Brown TM. Basic mechanisms in the pathogenesis of delirium. In:

Stoudemire A, Fogel BS, Greenberg DB, eds. The Psychiatric Care of

the Medical Patient. 2nd ed. New York: Oxford University Press;

2000.

9. Camus V, Gonthier R, Dubos G, Schwed P, Simeone I. Etiologic and

outcome profiles in hypoactive and hyperactive subtypes of delirium.

J Geriatr Psychiatry Neurol. 2000;13 Cole M, McCusker J,

Dendukuri N, Han L. The prognostic significance of subsyndromal

delirium in elderly medical inpatients. J Am Geriatr Soc.

2003;51:754–760.

10. Collinsworth AW, Priest EL, Campbell CR, Vasilevskis EE, Masica

AL. A review of multifaceted care approaches for the prevention and

mitigation of delirium in intensive care units. J

Intensive Care Med. 2016;31(2):127–141.11

11. Fang CK, Chen HW, Liu SI, Lin CJ, Tsai LY. Prevalence, detection

and treatment of delirium in terminal cancer inpatients: a prospective

survey. Jpn J Clin Oncol. 2008;

12. Fick D, Foreman M. Consequences of not recognizing delirium

superimposed on dementia in hospitalized elderly individuals. J

Gerontol Nurs. 2000;26:30–40.

13. Gagnon P, Allard P, Mâsse B, DeSerres M. Delirium in terminal

cancer: a prospective study using daily screening, early diagnosis, and

continuous monitoring. J Pain Symptom Manage.2000;19(6):

14. Häussinger D, Schliess F, Kircheis G. Pathogenesis of hepatic

encephalopathy. J Gastroenterol Hepatol. 2002;17 (Suppl 3):

15. Inouye, SK, RDG Westendorp, Saczynski JS. Delirium in elderly

people. Lancet. 2014;383

16. Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW. The

association between delirium and cognitive decline: a review of the

empirical literature. Neuropsychol Rev. 2004;

17. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC.

Haloperidol prophylaxis for elderly hip-surgery patients at risk for

delirium: a randomized placebo-controlled study. J Am Geriatr Soc.

2005;53:.

18. Lawlor PG, Gagnon B, Mancini IL, Pereira JL, Hanson J. Occurrence,

causes, and outcome of delirium in patients with advanced cancer: a

prospective study. Arch Intern Med. 2000;160(6):

19. Levkoff SE, Marcantonio ER. Delirium: a major diagnostic and

therapeutic challenge for clinicians caring for the elderly. Compr Ther.

1994;20:

20. Liptzin B, Levkoff SE. An empirical study of delirium subtypes. Br J

Psychiatry. 1992;161: Marcantonio ER, Flacker JM, Michaels M,

Resnick NM. Delirium is independently associated with poor

functional recovery after hip fracture. J Am Geriatr Soc. 2000;

21. McCusker J, Cole M, Dendukuri N, Belzile E, Primeau F. Delirium in

older medical inpatients and subsequent cognitive and functional

status: a prospective study. Can Med Assoc J. 2001;165:

22. McCusker J, Cole M, Dendukuri N, Han L, Belzile E. The course of

delirium in older medical inpatients: a prospective study. J Gen Intern

Med. 2003;18:.

23. Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R. A

multifactorial intervention to reduce prevalence of delirium and

shorten hospital length of stay. J Am Geriatr Soc. 2005;53(1):18–23.

24. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC. Delirium

and its motoric subtypes: a study of 614 critically ill patients. J Am

Geriatr Soc. 2006;54(3):

25. Ritchie J, Steiner W, Abrahamowicz M. Incidence of and risk factors

for delirium among psychiatric inpatients. Psychiatr Serv.1996;47(7):.

26. Rockwood K. The occurrence and duration of symptoms in elderly

patients with delirium. J Gerontol Med Sci. 1993;48:M162–M166.

27. Rockwood K, Cosway S, Carver D, Jarrett P, Stadnyk K. The risk of

dementia and death after delirium. Age Ageing. 1999;28:.

28. Rockwood K, Cosway S, Stolee P, Kydd D, Carver D. Increasing the

recognition of delirium in elderly patients. J Am Geriatr Soc. 1994;

29. Rudolph JL, Ramlawi B, Kuchel GA, McElhaney JE, Xie D.

Chemokines are associated with delirium after cardiac surgery. J

Gerontol A Biol Sci Med Sci. 2008;

30. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in

elderly patients: evaluation and management. Mayo Clin Proc.

1995;70:989–998.

31. Santana Santos F, Wahlund LO, Varli F, Tadeu Velasco I, Eriksdotter

Jonhagen M. Incidence, clinical features and subtypes of delirium in

elderly patients treated for hip fractures. Dement

Geriatr Cogn Disord. 2005;20(4)

32. Seaman JS, Schillerstrom J, Carroll D, Brown TM. Impaired

oxidative metabolism precipitates delirium: a study of 101 ICU

patients. Psychosomatics. 2006;47:56–61.

SOCIO DEMOGRAPHIC PROFORMA

Date of interviewing

Name: Phone number: WARD:

Address: Rural/Urban:

Age: (1) 16-30 years (2) 31-45 years (3) 46-60years 4)>60 years

Sex: (1) male (2) female (3) transgender

Religion: (1) Hindu (2) Muslim (3) Christian (4) others

Education: (1) Illiterate (2) Primary school (3) Middle school (4) High school (5) Intermediate / Post High school diploma (6)Graduate/Postgraduate (7) Professional/ Honours

Occupation: (1) Unemployed (2) Unskilled worker (3) Semi-skilled worker (4) skilled worker (5) Clerical, Shop owner, Farm (6) Semi profession (7) Profession (8) Student

Family income per month: (1) >=41985(2) 20992 - 41984 (3) 15706 - 20991(4) 10496 - 15705 (5) 6298 - 10495 (6) 2102 - 6297 (7) <=2101

Socio-economic status: (1) Upper(2) Upper Middle (3) Lower Middle(4)Upper Lower (5) Lower

Marital status: (1) single(2) married(3) widowed(4) Separated (5) divorced

Type of family: (1) nuclear (2) joint (3) extended (4) broken

1] Age of onset of alcohol use: 2] Duration 3]dependence pattern- 4] Amount intake per day:

• H/o concurrent substance use 1SLT 2Cannabis 3Nicotine 4Others

Last use of concurrent substance use:

Previous h/o seizures: Yes/No previous h/o co morbidity medical illness-

Previous h/o head injury: Yes/No duration-

Previous h/o delirium tremens: Yes/No on treatment-

Family h/o Alcohol use disorder: Yes/No

Family h/o psychiatric illness: Yes/No

DAY 1 3 5 7 9 11 13 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Laboratory investigations

• Hb :

• CBC: TC DC

• MCH: • MCV: • MCHC: • SGOT: • SGPT: • S.Bilirubin

• RBS: • Blood urea: • S.Creatinine: • Na: • K:

CT- BRAIN

MRI - BRAIN

OPNION

Total duration of delirium- Outcome – recovered/ death /discharge/absconded

Definite cause

4

Likelycause

3

Present and possible

contributor

2

Present but apparently

not contributing

1

Ruled out/not present/not relevant

0

Drug intoxication

Drug withdrawal

Metabolic/endocrine

Traumatic brain injury

Seizures

Infection (intracranial

Infection (systemic)

Neoplasm (intracranial)

Neoplasm (systemic)

Cerebrovascular Organ insufficiency

Other (central nervous system)

Others

INFORMED CONSENT FORM

STUDY: Study on Delirium etiology, clinical profile and outcome”.

STUDY CENTRE: Govt. Kilpauk Medical College Hospital, Chennai.

PATIENT’S NAME :

PATIENT’S AGE :

I.P NO. :

Patient may check ( ) these boxes

I confirm that I understood the purpose of the procedure for the above study.

( )

I had the opportunity to ask question and all my questions and doubts have

been answered to my complete satisfaction. ( )

I understand that my participation in the study is voluntary and that I am free to

withdraw at any time without giving reason, without my legal rights being

affected. ( )

I understand that the ethical committee members and the regulatory authorities

will not need my permission to look at my health records, both in respect of the

current study and any further research that may be conducted in relation to it,

even if I withdraw from the study I agree to this access.

( )

However, I understand that my identity will not be revealed in any information

released to third parties or published, unless as required under the law.

( )

I agree not to restrict the use of any data or results that arise from the study.

( )

I agree to take part in the above study and to comply with the instructions given

during the study and faithfully co-operate with the study team and to

immediately inform the study staff if I suffer from any deterioration in my

health or well being or any unexpected or unusual symptoms. ( )

I hereby consent to participate in this study. ( )

I hereby give permission to undergo complete clinical examination and

diagnostic tests including haematological, biochemical, radiological tests.

( )

Signature / thumb impression

Patient’s name and address:

Place:

Date:

Signature of the investigator:

Study investigator’s name:

Place:

PARTICIPANTS' INFORMATION SHEET

Investigator : Dr. C.J. Dhiinesh,

Name of the participant :

Study title: “Study on delirium etiology, clinical profile and outcome”.

You are invited to take part in this research study. We have got approval

from the IEC. You are asked to participate because you satisfy the eligibility

criteria.

What is the purpose of this research?

In this study, we aim to assess symptom profile and course of alcohol

withdrawal – delirium and other medical illness – delirium. To

compare clinical profile of delirium associated with alcohol withdrawal

Vs other medical illness - its, course of illness & outcome. To assess

the correlation of cognitive status and psychotic symptom

Benefits:

This study will benefit all people who are undergoing treatment for –

delirium and help improve the success rate of treatment, and also improves

their quality of life.

Discomforts and risks:

No interventional procedure is done in this study.

Confidentiality:

Patients who participate in the study and their details will be maintained

confidentially and at any cost, those details will not be let out.

Right to withdraw:

Patients will not be forced to complete the study. At any cost, in such

circumstances the treatment will not be compromised.

Signature/Thumb impression of the participant:

Signature of the investigator:

Date :

Place:

சுய ஒப்புதல் படிவம்

ஆய்வு ெசய்யப்படும் தைலப்பு:

"டிலிrயம் எேயாலாலஜி, மருத்துவ சுயவிவரம் மற்றும் விைளவு

பற்றிய ஆய்வு".

ஆராய்ச்சி நிைலயம்: கீழ்ப்பாக்கம் மருத்துவக்கல்லூr அரசு

மருத்துவமைன, ெசன்ைன.

பங்கு ெபறுபவrன் ெபய :

உறவு முைற:

பங்கு ெபறுபவrன் எண்:

பங்கு ெபறுபவ இதைன ( ) குறிக்கவும்

ேமேல குறிப்பிட்டுள்ள மருத்துவ ஆய்வின் விவரங்கள் எனக்கு

விளக்கப்பட்டது. என்னுைடய சந்ேதகங்கைளக் ேகட்கவும்,

அதற்கான தகுந்த விளக்கங்கைளப் ெபறவும் வாய்ப்பளிக்கப்பட்டது.

( )

நான் இவ்வாய்வில் தன்னிச்ைசயாகத்தான் பங்ேகற்கிேறன். எந்தக்

காரணத்தினாேலா எந்தக் கட்டத்திலும் எந்த சட்ட சிக்கலுக்கும்

உட்படாமல் நான் இவ்வாய்வில் இருந்து விலகிக் ெகாள்ளலாம்

என்றும் அறிந்து ெகாண்ேடன். ( )

இந்த ஆய்வு சம்மந்தமாகவும், ேமலும் இது சா ந்த ஆய்வு

ேமற்ெகாள்ளும்ேபாதும், இந்த ஆய்வில் பங்குெபறும் மருத்துவ

என்னுைடய மருத்துவ அறிக்ைககைளப் பா ப்பதற்கு என் அனுமதி

ேதைவயில்ைல என அறிந்துெகாள்கிேறன். நான் ஆய்வில் இருந்து

விலகிக் ெகாண்டாலும் இது ெபாருந்தும் என அறிகிேறன். ( )

இந்த ஆய்வின் மூலம் கிைடக்கும் தகவல்கைளயும், பrேசாதைன

முடிவுகைளயும் மற்றும் சிகிச்ைச ெதாட பான தகவல்கைளயும்

மருத்துவ ேமற்ெகாள்ளும் ஆய்வில் பயன்படுத்திக் ெகாள்ளவும்,

அைதப் பிரசுrக்கவும் என் முழு மனதுடன் சம்மதிக்கிேறன். ( )

இந்த ஆய்வில் பங்கு ெகாள்ள ஒப்புக்ெகாள்கிேறன். எனக்குக்

ெகாடுக்கப்பட்ட அறிவுைரகளின் படி நடந்துெகாள்வதுடன், இந்த

ஆய்ைவ ேமற்ெகாள்ளும் மருத்துவ அணிக்கு உண்ைமயுடன்

இருப்ேபன் என்றும் உறுதியளிக்கிேறன். என் உடல் நலம்

பாதிக்கப்பட்டாேலா அல்லது எதி பாராத வழக்கத்திற்கு மாறாக

ேநாய்க்குறி ெதன்பட்டாேலா உடேன அைத மருத்துவ அணியிடம்

ெதrவிப்ேபன் என உறுதி அளிக்கிேறன். ( )

இந்த ஆய்வில் எனக்கு மருத்துவப் பrேசாதைன ெசய்து ெகாள்ள

மற்றும் ஆய்வில் பங்ேகற்க நான் முழு மனதுடன் சம்மதிக்கிேறன்.

( )

பங்ேகற்பவrன் ைகெயாப்பம் / கட்ைடவிரல் ேரைக:

இடம்: ____________________________

ேததி: _____________________________

பங்ேகற்பவrன் ெபய மற்றும் விலாசம்::

ஆய்வாளrன் ைகெயாப்பம் _________________________

இடம் _________________________

ேததி __________________________

ஆய்வாளrன் ெபய ____________________________

ஆராய்ச்சி தகவல் தாள்

கீழ்பாக்கம் அரசு ெபாது மருத்துவமைனயில் டிலிrயம்

எேயாலாலஜி, மருத்துவ சுயவிவரம் மற்றும் விைளவு பற்றிய

ஆய்வு

பங்ேகற்க நாங்கள் விரும்புகிேறாம். இந்த ஆராய்ச்சியில்

பங்ேகற்பதால் தங்களது ேநாயின் ஆய்வறிக்ைகேயா அல்லது

சிகிச்ைசேயா பாதிக்கப்படாது என்பைதயும் ெதrவித்துக்

ெகாள்கிேறாம்.

இந்த ஆராய்ச்சியின் முடிவுகைள அல்லது கருத்துகைள

ெவளியிடும் ேபாேதா அல்லது ஆராய்ச்சியின் ேபாேதா தங்களது

ெபயைரேயா அல்லது அைடயாளங்கைளேயா ெவளியிடமாட்ேடாம்

என்பைதயும் ெதrவித்துக் ெகாள்கிேறாம்.

இந்த ஆராய்ச்சியில் பங்ேகற்பது தங்களுைடய விருப்பத்தின்

ேபrல் தான் இருக்கிறது. ேமலும் நங்கள் எந்ேநரமும் இந்த

ஆராய்ச்சியில் இருந்து பின்வாங்கலாம் என்பைதயும்

ெதrவித்துக்ெகாள்கிேறாம்.

இந்த சிறப்புப் பrேசாதைனகளின் முடிவுகைள ஆராய்ச்சியின்

ேபாேதா அல்லது ஆராய்ச்சியின் முடிவின் ேபாேதா தங்களுக்கு

அறிவிப்ேபாம் என்பைதயும் ெதrவித்துக்ேகாள்கிேறாம்.

ஆராய்ச்சியாள ைகெயாப்பம் பங்ேகற்பாள ைகெயாப்பம்

ேததி: