Delirium 2024-02 PDF

Delirium Gonzalez MD START  Student´s Resources: Delirium Etiology Clinical scenario Diagnosis  INTRODUCTION: Clinicians fail to recognize and address delirium in up to 80% of cases  Concept #1: Delirium is a life-thre...

Delirium Gonzalez MD START  Student´s Resources: Delirium Etiology Clinical scenario Diagnosis  INTRODUCTION: Clinicians fail to recognize and address delirium in up to 80% of cases  Concept #1: Delirium is a life-threatening neuropsychiatric emergency characterized by an acute change in attention (global cognition) and awareness, caused by a severe systemic illness and cannot be better explained by a pre- existing neurocognitive disorder. Primary features: 1. FATAL (mortality rate 22% to 76% with 20% increase in the relative risk of mortality with each day of delirium. Mortality is as high as mortality rates associated with myocardial infarction or sepsis) 2. Transient 3. Reversible 4. Preventable (1 of the 6 leading causes of preventable conditions in hospitalized patients) 5. Poor clinical outcomes if not treated quickly (delirium is a life-threatening condition that is o en missed and poorly managed) Delirium is a life-threatening condition that is o en missed and poorly managed. UAG The Diagnostic and Statistical Manual of Mental Disorders, 5th edition  Concept #2: Delirium is an acute medical emergency UAG The Diagnostic and Statistical Manual of Mental Disorders, 5th edition  Concept #3: Delirium is a neuropsychiatric symptom secondary to systemic disturbances resulting from an acute and/or severe systemic illness Delirium is a manifestation or a complication of an underlying medical condition(s) and is o en considered multifactorial. UAG The Diagnostic and Statistical Manual of Mental Disorders, 5th edition  Epidemiology In general, delirium can be found wherever there are sick patients. Up to 83% of all patients at the end of life. Among critically ill patients in ICU (70-80%) Up to 60% of patients in nursing homes or postacute settings In the emergency department,about 40% of patients have delirium 30% of older medical patients experience delirium at some time during hospitalization (1 in 7 hospitalized patients overall) Delirium complicates 15% to 50% of major operations in older adults Following hospitalization, the one-year mortality rate associated with cases of delirium is 35% to 40%. clinicians fail to recognize and address postoperative delirium in up to 80% of cases UAG The Diagnostic and Statistical Manual of Mental Disorders, 5th edition  Risk factors (delirogenic factors) Predisposing factors: depict the vulnerability of an individual to develop delirium and these, are usually present prior to admission to the hospital and are considered to have a larger contribution than the precipitating factors for the onset of delirium. Precipitating factors: newly acquired insults or hospital-related factors, which contribute to the development of delirium There is some overlap in these factors. UAG NATURE REVIEWS | DISEASE PRIMERS | Article citation ID: (2021) 6:90  Precipitating or predisposing? Advanced age (>65 years) and dementia are the two most common risk factors for delirium. Other common risk factors for delirium are: Visual and hearing impairments Sensory deprivation Reduced mobility Dehydration Poor nutrition Polypharmacy Multiple co-morbidities In older patients with hip fractures, delirium is the most common postoperative complication Older people are more likely to have these risk factors than the general population and are therefore at greater risk of delirium Older people are more likely to have these risk factors than the general population and are therefore at greater risk of delirium UAG NATURE REVIEWS | DISEASE PRIMERS | Article citation ID: (2021) 6:90  Precipitating or predisposing? An organized approach may be facilitated by use of the mnemonic “WHHHIMP,” indicating 7 potentially fatal etiologies: Wernicke's encephalopathy Hypoxemia Hypoglycemia Hypertensive crisis Intracranial bleeding Meningitis/encephalitis Poisoning. UAG NATURE REVIEWS | DISEASE PRIMERS | Article citation ID: (2021) 6:90  Risk factors (2) UAG  Risk factors (3): I WATCH DEAD/DELIRIUM UAG NATURE REVIEWS | DISEASE PRIMERS | Article citation ID: (2021) 6:90 Etiopathogenesis  Etiopathogenesis + UAG  Etiopathogenesis + UAG  In the majority of cases, delirium is the sole ! manifestation of the systemic illness, with no other apparent abnormalities Increasing evidence argues that health-care providers need to assess the mental status of the patient as the “sixth vital sign.”  Clinical scenario It is characterised by four distinct clinical hallmarks: 1. Altered consciousness: newly sleepy (reduced responsiveness), hyperactive (severe agitation) or alternating states 2. Cognitive change: inattention 3. Acute onset: sudden change in the patient 4. Fluctuating course: unpredictable changing cognition and consciousness. UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68  Cognitive symptoms: Inattention in delirium INATTENTION is considered to be the most consistent feature and accordingly is included as a diagnostic criterion. Disturbance in attention involves all aspects, i.e., ability to focus, shi and sustain attention. Impairments in memory can involve both short- and long-term memory with significant impairment in recent memory. Disorientation to time, place and person is also very common. Visuo-spatial disturbances and executive dysfunction when present impair the functionality of the patients. The most critical mistake one can make is viewing acute inattention in the elderly as a typical and benign aspect of aging. UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68  Non-Cognitive symptoms 1. Disturbances in the sleep wake cycle 2. A ective lability 3. Perceptual abnormalities (hallucinations, illusions etc.) and delusions. 4. The motoric symptoms of delirium include: An increase or decrease in the psychomotor activity. UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68  DX (1): DSM5 and CAM (same content) UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68  Clinical Classification (Treatment Foundation) Hyperactive (5%) (agitated neurological status) In all types of delirium, there will o en be changes to vital signs; this can be an Hypoactive (30%) (depressed neurological status) indication of impending deterioration Mixed (65%) UAG  Clinical Classification (Treatment Foundation) The features of delirium tend to fluctuate in severity (hyperactive, hypoactive, calm). UAG Treatment  HOW SHOULD DELIRIUM BE ASSESSED? Delirium “always” has a medical cause. Since delirium, by definition, always has a medical cause, the identification of such a cause must be aggressively pursued. Delirium is o en multifactorial. In many cases, more than 1 factor is responsible for the development of delirium. HOW SHOULD AGITATION IN DELIRIUM BE ASSESSED? When agitation occurs, patient may be impulsive and attempt to get out of bed, to wander, and to fall (which may lead to further injury or death) and attempt to remove IV lines, tubes, or catheters. Removal of potentially dangerous items from the room and the surrounding area, institution of sitters to provide greater supervision, and initiation of pharmacologic treatment are o en necessary. WHICH PHARMACOLOGIC AGENTS EFFECTIVELY TREAT AGITATION ? Although the best treatment of delirium is one that treats the problem specifically, the symptoms of delirium (agitation) o en decrease with use of pharmacologic agents. Antipsychotics are most frequently used for control of agitation, paranoia, and psychosis associated with delirium. Haloperidol, administered intravenously-intramuscularly, is the preferred treatment for agitated delirious patients (American Psychiatric Association) despite the fact that this route of administration has not been approved by the US Food and Drug Administration and that it now carries “warnings” associated with the risk of ventricular arrhythmia, including torsades de pointes. UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68  Pharmacological treatment considerations depend on: The presence or absence of agitation. In patients without agitation but with a depressed level of consciousness, pharmacological treatment may exacerbate the depressive state. However, in patients exhibiting agitation that poses a risk to their own safety, healthcare providers, and family members, the clear indication is to use pharmacological treatment, such as antipsychotics. UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68 UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68 Delirium and agitation: Treatment  Loved Ones Experience It is also vital to acknowledge the experience of the loved ones of the patient with delirium. O en naïve to what delirium is and how it may present, witnessing a delirious episode can be very alarming for the patientʼs family members, partners, and friends. "My dad did not recognise me which I would say even against the episodes where he was seeing rats and spiders crawling over people and up walls, I think probably the most distressing thing was not being recognised by my dad, that was the frst time I ever experienced anything like thatʼ, he was not himself. Loved ones can be vital in helping healthcare professionals spot delirium and monitor its progress. It is important to heed comments by family members about any changes in behaviour. UAG 1Disease PRIMERS | Article citation ID: ( 2021) 6:68 UAG UAG  Any questions? UAG