NEUROCOGNITIVE
DISORDERS
Delirium
Delirium
It is a neuropsychiatric syndrome also
called acute confusional state or acute
brain failure that is common among the
medically ill and often is misdiagnosed as
a psychiatric illness which can result in
delay of appropriate medical intervention.
There is significant mortality associated
with delirium so identifying it is crucial!
Criteria for Diagnosis
1. Disturbance of consciousness with reduced ability to
focus, sustain or shift attention.
2. A change in cognition or development of perceptual
disturbances that is not better accounted for a
preexisting, existed or evolving dementia.
3. The disturbance develops over a short period of time
and tends to fluctuate during the course of the day
4. There is evidence from this history, physical
examination or labs that the disturbance is caused
by the physiological consequence of a medical
condition.
Clinical characteristics
Develops acutely (hours to days)
Characterized by fluctuating level of
consciousness
Reduced ability to maintain attention
Agitation or hypersomnolence
Extreme emotional lability
Cognitive deficits can occur
Clinical characteristics:
cognitive deficits
Language difficulties: word finding difficulties,
dysgraphia
Speech disturbances: slurred, mumbling,
incoherent or disorganized
Memory dysfunction: marked short-term memory
impairment, disorientation to person, place, time.
Perceptions: misinterpretations, illusions,
delusions and/or visual (more common) or
auditory hallucinations
Constructional ability: can’t copy a pentagon
Types of delirium
Hyperactive or hyperalert
the patient is hyperactive, combative and
uncooperative.
May appear to be responding to internal stimuli
Frequently these patients come to our attention
because they are difficult to care for.
Hypoactive or hypoalert
Pt appears to be napping on and off
throughout the day
Unable to sustain attention when awakened,
quickly falling back asleep
Misses meals, medications, appointments
Does not ask for care or attention
This type is easy to miss because caring for
these patients is not problematic to staff
Mixed
a combination of both types just
described
The most common types are hypoactive
and mixed accounting for approximately
80% of delirium cases
Epidemiology- Delirium occurs in:
approximately 40% of hospitalized elderly
pts >65 years
approximately 50% of pts post-hip fracture
approximately 30% of pts in surgical
intensive care units
approximately 20% of pts on general
medical wards
approximately 15% of pts on general
surgical wards
Etiology
Anything that hurts the brain or
impairs its proper functioning can
provoke a delirium!
Brain’s
way of demonstrating “acute
organ dysfunction”
Etiology Cont.
It is usually multifactorial
Systemic illness
Medications- any psychoactive
medication can cause delirium
Presence of risk factors
Etiology:
Systemic illnesses
Infections
Electrolyte abnormalities
Endocrine dysfunctions (hypo or hyper)
Liver failure- hepatic encephalopathy
Renal failure- uremic encephalopathy
Pulmonary disease with hypoxemia
Cardiovascular disease/events: CHF, arrhythmias, MI
CNS pathology: tumors, strokes, seizures
Deficiency states: Thiamine, nicotinic or folic acid, B12
Etiology: Drugs
Anticholinergics (furosemide, digoxin,
theophylline, cimetidine, prednisolone,
TCA’s, captopril)
Analgesics (morphine, codeine..) & Steroids
Antiparkinson (anticholinergic and
dopaminergic)
Sedatives (benzodiazepines, barbiturates)
Anticonvulsants
Etiology: Drugs continued
Antihistamines
Antiarrhythmics (digitalis)
Antihypertensives
Antidepressants
Antimicrobials (penicillin, cephalosporins,
quinolones)
Sympathomimetics
Predisposing risk factors
>60 years of age Depression
Male sex Functional
Visual impairment dependence
Dehydration
Underlying brain
pathology such as Substance
stroke, tumor, abuse/dependence
vasculitis, trauma, Hip fracture
dementia Metabolic
Major medical illness abnormalities
Recent major surgery Polypharmacy
Precipitating risk factors
Meds (see list) Orthopedic surgery
Severe acute illness Cardiac surgery
UTI ICU admission
Hyponatremia High number of
Hypoxemia hospital procedures
Shock
Anemia
Pain
Important Rule-outs
Subdural hematoma
Wernicke’s
Septicemia
Hypoxia
Subacute bacterial
Hypoglycemia
endocarditis
Hypertensive Hepatic or renal
encephalopathy
failure
Meningitis/encephalitis Thyrotoxicosis/myx-
Poisoning edema
Anticholinergic Delirium tremens
psychosis Complex partial
seizures
The pathophysiology of delirium
Many hypotheses exist including:
Neurotransmitter abnormalities
Inflammatory response with increased cytokines
Changes in the blood-brain barrier permeability
Widespread reduction of cerebral oxidative
metabolism
Increased activity of the hypothalamic-pituitary
adrenal axis
How to evaluate a patient with
suspected delirium
Look at chart notes with particular attention to level
of consciousness, behavior and level of
cooperativeness
Look at the overall time course
Review med list including scheduled, prns doses,
recent meds discontinued or started
Evaluate for recent medical illness and
interventions
Screen for history of substance dependence to
determine risk of withdrawal
How to evaluate a patient with
suspected delirium
Review diagnostic studies including labs,
imaging, vital signs
Interview patient paying close attention to
concentration, level of somnolence, mood
lability, executive function, short term
memory deficits, kinetics. Use MMSE.
Gather collateral information from
family/friends regarding baseline function,
personality, psych history
Testing
Mini mental status exam (MMSE) is not
sensitive in identifying delirium however
repeated MMSEs can reveal waxing and
waning course
Most sensitive items are serial 7’s,
orientation, recall memory
Tests of attention include serial 7’s, spelling
WORLD backwards, months of the year
backward, counting down from 20
Differentiating between delirium
and a psychiatric disorder
Clouded consciousness or decreased level
of alertness
Disorientation
Acuity of onset and course- serial mental
status exams can help demonstrate this
Age >40 without prior psych history
Presence of risk factors for delirium, recent
medical illness or treatment
Dementia vs Delirium
Dementia has an insidious onset, chronic
memory and executive function disturbance,
tends not to fluctuate. In delirium cognitive
changes develop acutely and fluctuate.
Dementia has intact alertness and attention but
impoverished speech and thinking. In delirium
speech can be confused or disorganized.
Alertness and attention wax and wane.
Schizophrenia vs Delirium
Onset of schizophrenia is rarely after 50.
Auditory hallucinations are much more
common than visual hallucinations
Memory is grossly intact and disorientation
is rare
Speech is not dysarthric
No wide fluctuations over the course of a
day
Mood disorders vs Delirium
Mood disorders manifest persistent rather than
labile mood with more gradual onset
In mania the patient can be very agitated however
cognitive performance is not usually as impaired
Flight of ideas usually have some thread of
coherence unlike simple distractibility
Disorientation is unusual in mania
Treatment
First and foremost treat the underlying
cause
Environmental interventions: cues for
orientation (calendar, clock, family
pictures, windows), frequently reorient the
patient, have family or friends visit
frequently making sure they introduce
themselves, minimize staff switching.
Minimize psychoactive medications
Treatment-meds
Antipsychotics decrease psychotic symptoms,
confusion, agitation
Antipsychotics- IV Haldol is first line because of
significantly reduced risk of Extrapyramidal side
effects. Onset of action within 5-20 minutes.
After IV dose established transition to BID or qhs
oral dose and taper.
Some data now supports use of atypical
antipsychotics: Risperdal 0.5-2mg, Quetiapine
12.5-50mg, Olanzapine 2.5-10mg.
Course and Prognosis
Prodromal symptoms may occur a few days prior to
full development of symptoms
The symptoms will continue to progress/fluctuate until
underlying cause treated
Most of the symptoms of delirium will resolve within a
week of correction/improvement of the underlying
etiology HOWEVER symptoms may wax and wane. In
some patients it can take weeks for the symptoms to
resolve.
Some patients, particularly older patients, may never
return to baseline
Education
Let the family know what is going on including
that delirium waxes and wanes and can last for
several weeks
Once the patient starts to improve explain to
them what delirium is, how common it is and
the usual course. It is very frightening for them
and may fear they have a psychiatric illness.
***
THANKS
