Delirium resident survival guide

Template:Delirium resident survival guide Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]

Delirium resident survival guide Microchapters
Overview
Classification
Causes
Diagnosis
Treatment
Prophylaxis
Do's
Dont's

Overview

Delirium is characterized by acute onset (developing over hours to days), and a fluctuating decline in attention-focus, perception, and cognition. Infection, neurological diseases and metabolic derangement are the common causes of the delirium. Treatment of underlying etiology is crucial in the management of delirium. Delirium is managed conservatively. If non-pharmacological interventions fail, antipsychotic with a minimal anticholinergic profile, like haloperidol and olanzapine are used. Extremely agitated patients are managed by restrains and sedatives.

Classification

• Hyperactive: Increased psychomotor activity, which may co-occur with increased mood lability, agitation, and/or non-cooperative attitude towards medical treatment.
• Hypoactive: Decreased level of psychomotor activity, which may exist along with increased sluggishness, lethargy or stupor.
• Mixed level of activity: Normal level of psychomotor activity, individuals with rapidly fluctuating activity are also included in this category.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Delirium by itself is not a life threatening condition.

Common Causes

• Infections (pneumonia, UTI, sepsis, CNS infections)
• Neurological (stroke, subdural haematoma, epilepsy)
• Cardiovascular (myocardial infarction, heart failure)
• Respiratory (pulmonary embolism, hypoxia)
• Electrolyte imbalance (dehydration, renal failure)
• Endocrine & metabolic (diabetic ketoacidosis, cachexia, thiamine deficiency, thyroid dysfunction)
• Drugs (antidepressants, antiparkinsonian drugs, sedatives, lithium)

FIRE:Focused Initial Rapid Evaluation of Suspected Delirium

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in salmon color signify that an urgent management is needed.

Identify if, ❑ The patient is extremely agitated and is harm to self or others

❑ Administer restrains, if patient can not be redirected ❑ Use bezodiazepines to further curtail agitation

Continue with the diagnostic approach

Patients with severe agitation that does not improve: ❑ Give Morphine, paralyze, and if required put on artificial respirator

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention. Shown below is an algorithm summarizing the diagnostic approach to delirium based on the 1999-2000 APA (American Psychiatric Association) guideline, 2006 British Geriatric Scociety guideline and 2010 NICE (National Institute for Health and Care Excellence) guideline for the management of delirium.

Characterize the symptoms: ❑ Impaired sleep awake cycle ❑ Change in psychomotor activity ❑ Change in social behavior and emotional disturbances with rapid and unpredictable shifts from one emotional state to another e.g. from anxiety, fear, depression, irritability, anger, euphoria to apathy ❑ Nonspecific neurological abnormalities like : ❑ Tremor ❑ Myoclonus ❑ Asterixis ❑ Reflex and muscle tone changes ❑ Change in perception and cognitive functions like memory, orientation, visuospatial ability, or language.

Obtain detailed history: ❑ Onset ❑ Previous intellectual function ❑ List of medications/drugs ❑ Sedative ❑ Hypnotics ❑ Narcotic ❑ Anticholinergic ❑ Corticosteroid ❑ Polypharmacy ❑ Alcohol withdrawal or other drugs) ❑ Collateral history from relatives, out patient care providers, case managers ❑ Baseline blood pressure ❑ Previous medical history including psychiatric diagnosis ❑ Sensory deficits ❑ Hearing aids/glasses ❑ Symptoms suggestive of underlying infection Identify if patient is at high risk to develop delirium: ❑ Underlying cognitive impairment ❑ Older age (>65 years) ❑ History of delirium, stroke, neurological disease, falls or gait disorder ❑ Associating multiple medical aliments ❑ Male gender ❑ Sensory impairment (hearing or vision) ❑ Immobilization (catheters or restraints) ❑ Acute neurological pathology (e.g. acute stroke usually involving right parieta region, intracranial hemorrhage, meningitis, encephalitis) ❑ Intercurrent illness (for example, infections, iatrogenic complications, severe acute illness, anemia, dehydration, poor nutritional status, fracture or trauma, HIV infection) ❑ Metabolic impairment ❑ Surgery especially orthoscopic surgeries of the hip ❑ Stressful surroundings (for example, admission to an intensive care unit) ❑ Pain ❑ Emotional stress ❑ Lack of sleep

Diagnosis ❑ Diagnosis is made by DSM V criteria or in the ICU by CAM scale ❑ DSM V Diagnostic Criteria Diminished focus or concentration and lack of knowledge or perception of the surroundings Developing in a brief period of time accounting to hours to days, a shift from a baseline which change in severity in it’s course Also, interference in faculties of cognition like, memory, orientation, visuospatial ability, or language 1st and 3rd criteria are not a result of any previous, current, or developing neurocognitive disorder and is not related to a shift in arousal status e.g. coma The manifestation of the disturbances resulting as a Physiological sequel of a medical condition Intoxication or withdrawal of substance(s)/ medicine(s)/ toxin(s) Is due to multiple etiologies As explained by the history, physical examination, or laboratory findings ❑ Specify if ❑ Substance intoxication delirium or ❑ Substance withdrawal delirium or ❑ Delirium caused by another medical condition or ❑ Delirium caused by multiple etiologies or ❑Specify if delirium is ❑ Acute or ❑ Persistent ❑Specify if delirium is ❑ Hyperactive or ❑ Hypoactive or ❑ Mixed level of activity Or, ❑ Confusion Assessment Method for the ICU (CAM-ICU) Diagnosed if, feature 1 and 2 are present along with 3 or 4 Onset of symptoms, is acute(change from baseline) or fluctuating, calibrated by Richmond Agitation Sedation Scale or Glasgow Coma Scale Inability to focus as measured by Attention Screening Examination Thinking is not organized Altered level of consciousness if vigilant, lethargic, stupor, coma

If delirium is diagnosed, do focused examination to find out underlying etiology: Vital signs ❑ Blood pressure ❑ If lower than baseline: Shock, drug overdose e.g. opiate ❑ If higher than baseline: Increased intracranial pressure, drug overdose e.g. cocaine, hypertensive crisis Pulse ❑ Tachycardia:Shock, drug overdose eg. cocaine ❑ Bradycardia:Increased intracranial pressure drug overdose eg. opiate Respiratory rate ❑ If lower: Drug overdose e.g. opiates ❑ If higher: Pulmonary pathology like pneumonia, asthma, COPD Raised temperature ❑ Suspect cholinergic drug overdose ❑ Underlying infection Skin ❑ Jaundice: Liver and biliary pathology ❑ Cherry red appearance: CO poisoning ❑ Edema: Heart failure, liver failure, renal failure, malnutrition ❑ Cyanosis:Heart failure, lung pathology, drug overdose ❑ Needle marks: Drug overdose Appearance ❑ Cherry red tongue, lip fissure etc suggestive of malnutrition ❑ Unkempt and unhygienic: Schizophrenia Neurological examination ❑ Emergence of new focal neurological signs: Cerebrovascular event ❑ Trauma to head: hemorrhage and increased intracranial pressure ❑ Meningeal signs: Meningitis ❑ Neurodegenerative diseases: Parkinsonism, alzheimer's disease etc. ❑ Mental status examination: Dementia Cardiovascular examination ❑ New onset murmur: Myocardial infarction ❑ S3 and S4: Heart failure ❑ Murmur: underlying shunts and cardiac valve pathology Respiratory examination ❑ Inspiratory crackles: Suggestive of congestive heart failure ❑ Wheeze may be because of asthma or COPD ❑ Increased tactile vocal fermitus, egophony and dull on percussion may indicate underlying pneumonia Abdominal examination ❑ Ascites: Liver failure, heart failure, kidney failure ❑ Organomegaly: Liver failure, portal hypertension, hepatic encephalopathy ❑ Distended bladder: Urinary obstruction leading urinary tract infection.

If delirium is not diagnosed, ❑ Re-access patient multiple times a day, diagnosis of delirium may be missed because of it's fluctuating course ❑ When delirium can not be differentiated from dementia or delirium and dementia co-exists, provide treatment delirium ❑ Consider following differential diagnosis, Psychiatric illness: Psychotic disorders like, brief psychotic disorder, schizophrenia, schizophreniform disorder, bipolar disorder etc. Acute stress disorder Malingering and factitious disorder Confusional states Other neurocognitive disorders e.g. dementia Neurological Disorders: Frontal lobe disorders such as tumor Cerebral contusion Bacterial meningitis Parital lobe disorders like wernicke's aphasia Nonconvulsive epileptic episodes Hepatic encephalopathy Sundowning Viral encephalitis

Investigations ❑ Delirium is a clinical diagnosis, investigations are aimed to reveal underlying etiology. ❑ Lab investigations: Complete blood count (CBC) Glucose Calcium Urinalysis Electrolyte Blood urea nitrogen (BUN) / creatinine Arterial blood gases Pulse oximetry Vitamin B12 Folate levels Thyroid function test Urine culture Blood culture Toxic screen of blood and urine If indicated: Arterial blood gas Specific cultures e.g. sputum Lumbar puncture if, Meningism Headache Unexplained fever EEG to rule out Dementia Non‑convulsive status epilepticus and temporal lobe epilepsy Conditions that can be identified on EEG e.g. metabolic encephalopathy or infectious encephalitis Focal intracranial lesion, or it's a global abnormality ❑ Imaging Studies CT scan of the brain: Focal neurological signs Head injury Increased intracranial pressure. MRI of brain: Intracranial bleed Brain tumor Dementia etc.

Treatment

Treatment: ❑ Treat underlying etiology. ❑ Discontinue/ adjust dose of the offending drugs Antiarrhythmic Antihistamine Antiparkinsonian drugs such as benzatropine Antispasmodic Benzodiazepine Diuretic e.g. furosemide Incontinence medicines e.g. oxybutynin Opioid analgesics Tricyclic antidepressant Non-pharmacological treatment ❑ Avoid unnecessary movement of the patient ❑ Maintain continuity of care from caring staff ❑ Avoid physical restraints ❑ Involve family members in care ❑ Have recognizable faces at the bedside ❑ Sensory aids should be available and working where necessary ❑ Maintenance or restoration of normal sleep patterns ❑ Avoid sudden and irritating noise (e.g. Pump alarms) ❑ Careful management of bowel and bladder elimination ❑ Having a means of orientation available (such as a clock and a calendar) ❑ Reassurance and explanation to the patient ❑ Verbal and non-verbal de-escalation techniques to calm the patient. ❑ T-A-DA Method (Tolerate, Anticipate, Don't Agitate) ❑ Tolerate patient behavior, as long as the patient or other people are not in danger ❑ Provide greater mobility by removing unnecessary attachments like catheter ❑ Reduce agitation, do not reorient if reorientation causes agitation ❑ Provide supervision, anticipate behavior to keep the patient safe. ❑ Wandering and rambling speech can be tackled with the following strategies ❑ Closely observe wandering patients ❑ Distract agitated wandering patient, if required, seek help from relatives ❑ Attain to the common stressors causing agitation, such as pain, and thirst ❑ Do not agree with rambling talk, acknowledge the feelings expressed and ignore the content, or change the subject, or tactfully disagree if the topic is not sensitive. ❑ If non pharmacological techniques fail, or if de-escalation techniques are inappropriate, use pharmacological treatment to tackle delirium.

Medical Management: ❑ Antipsychotic Contraindicated in parkinson disease, neuroleptic malignant syndrome, dementia with lewy bodies. Haloperidol is a gold standard, olanzepine can also be used. Geriatric population, and seriously ill patients: 0.25 - 0.50mg four hourly Healthier patients: 2mg - 3mg per day Very agitated patients: 5mg - 10mg per hour iv IV route can reduce extrapyramidal side effects Droperidol can be given alone or after haloperidol, if quicker results are desired EKG monitoring may be needed to find out QTc interval ❑ Sedative such as benzodiazepine Contraindicated in hepatic encephalopathy, respiratory depression or compromised lung functions. To conduct required diagnostic procedures or to deliver treatment If patient is danger to others or themselves Highly agitated or hallucinating patient Alcohol withdrawal Benzodiazepine withdrawal When antipsychotics are contraindicated, parkinson's disease, neuroleptic malignant syndrome, dementia with Lewy bodies ❑ Cholinergic: Physostygmine is used if caused by anticholinergic medications ❑ Morphine and paralysis: Contraindicated in head trauma. Used in extremely agitated patients, unresponsive to other treatment, who may need sedation and ventilator support It increases oxygenation and skeletal muscle exertion Morphine is useful when pain is an important aggravating factor. But, opiates etc. can exacerbate delirium because of anticholinergic properties

Restrains: Used as a last resort in a severe delirium Must be avoided as it can increase agitation and risk of injury Local laws on restrains must be well known to care providers.

If Improvement: ❑ Continue the treatment ❑ Monitor the patient by CAM-ICU scale ❑ Avoid sedatives ❑ Avoid restrains.

Discharge & Follow up ❑ Before Discharge: Housing and living issues like washing, dressing, medication etc. must be sorted out before the patient is relieved from the hospital Cognitive and functional status (e.g. using standardized tools such as AMT and Barthel Index) must be accessed Consult all relevant disciplines in the hospital and out patient care providers Must be referred to a Geriatrician, Psychiatrist, Social Worker, etc. for further work up and management. ❑ Education and Reassurance: Explain transient nature of delirium to patients and their families help them cope ❑ Post Delirium Psychiatric Management: Patients may remember delirium after recovery, which can cause significant distress, and frightening recollections. Utilize standard psychiatric interventions used for traumatic experiences.

If no Improvement ❑ Re-evaluate the patient ❑ Consider prolonged delirium syndrome ❑ Consider the diagnosis of dementia.

Dose of Haloperidol

Geriatric population, and seriously ill patients	0.25 - 0.50mg four hourly
Healthier patients	2mg - 3mg per day
Very agitated patients	5mg - 10mg per hour iv

Reversible Causes of Delirium	Offending Drugs causing Delirium
❑ Hypoglycemia ❑ Hypoxia or anoxia ❑ Hyperthermia ❑ Severe hypertension ❑ Alcohol or sedative withdrawal ❑ Wernicke encephalopathy	❑ Antiarrhythmic ❑ Antihistamine ❑ Antiparkinsonian drugs such as benzatropine ❑ Antispasmodic ❑ Benzodiazepine ❑ Diuretic e.g. furosemide ❑ Incontinence medicines e.g. oxybutynin ❑ Opioid Analgesics ❑ Tricyclic antidepressant

Prophylaxis

Targeted symptomatic intervention can help prevent the emergence of delirium, however, non pharmacological approach can curtail the incidence of delirium and not effective in preventing recurrence of delirium once delirium has set it.

Non pharmacological approach:

❑ Curtail cognitive decline:

• Write names of care providers, the day’s schedule on board
• Constantly reorient patients to surroundings
• Activities to stimulate cognitive actions like discussion of current events, structured reminiscence, or word games

❑ Curtail sleep impairment:

• Reduce environmental noise
• Relaxing activities such as music, back massage

❑ Curtail immobility:

• Minimal use of catheter or other aids which promotes immobility
• Early mobilization
• Incorporation of an exercise regiment

❑ Manage difficulties in sight:

• Use of visual aids
• Use of large fluorescent tapes or objects with illuminations to help in vision

❑ Manage difficulties in hearing:

• Use of aids
• Ear care

❑ Avoid dehydration:

• Regular hydration
• Early recognition and prompt treatment.

❑ Delirium in ICU can be predicted by [PREDELIRIC] model

❑ Low dose haloperidol, if given prophylactically in lower doses, have following benefits,

• Lower mortality
• Lower delirium incidence
• More delirium free days
• Patients are less likely to remove their tubes or catheters
• Patients with a higher risk of developing delirium benefited more
• ICU readmission rate was lower.

Drawbacks for prophylactic treatment with Haloperidol:

• Unnecessary treatment to patients who were not destined to develop delirium,
• Side effects of treatment, however during clinical studies there was only a marginal prolongation of QTc and no one developed ventricular arrhythmias. More studies neeeds to be done on prophylaxis of delirium.

Do's

• Access the patients multiple times a day, diagnosis of delirium can be missed because of transient nature of it's symptoms.
• Use antipsychoticwith caution,

• Give for a short period of time - approximately 1 week.
• Start with the lowest possible dose and titrated according to symptoms.
• Do EKG monitoring to calibrate QTc interval which is one of the serious side effect of antipsychotic, and order cardiology consult if QTc interval is more than 450msec or it is greater than 25% baseline. Dose adjustment or discontinuation of antipsychotic medication may be warranted.
• Do watch for side effects: Haloperidol can cause sedation and hypotension, lowering of seizure threshold, galactorrhea, elevation in liver enzyme levels, inhibition of leukopoiesis, neuroleptic malignant syndrome, and withdrawal movement disorders are rare side effects of antipsychotic medication.
• Do watch complications of anti psychotics in elderly, w.r.t. extra pyramidal side effects, falls, hip fracture.

• Use sedatives must be used with caution with minimum possible dosage and discontinue if they are not required.
• Use benzodiazepine with caution if liver functions are compromised. It can cause behavioral dis-inhibition, amnesia, ataxia, respiratory depression, physical dependence, rebound insomnia, withdrawal reactions, and delirium. Adolescents and pediatric may suffer from dis-inhibition reactions, emotional lability, increased anxiety, hallucinations, aggression, insomnia, euphoria, and in-coordination.
• Use anticholinergic with caution, It can cause bradycardia, nausea, vomiting, salivation, and increased gastrointestinal acid. Physostigmine can cause seizure.
• Be aware of medicolegal issues:

• Because of transient impairment in cognition, orientation and other higher functions, patient may not be able to provide consent or there can be impairment of competency. Delirium itself does not make patient incompetent by law. Emergency cases can be treated without obtaining consent, however non emergency cases pose an ethical dilemmas.
• Local laws on restrains must be well known to the care provider.

• Educate family members and the patient to explain transient nature of delirium. Provide appropriate psychiatric care if the patient suffers distress and frightening recollection of delirium .

Don'ts

• Do not give sedatives in hypoactive delirium.
• Do not catheterize, or use restraint
• Do not acknowledge rambling speech and argue with the patients.
• Do not discharge patients without setting up an appropriate outpatient care.

References

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