Delirium Clinical scenario A 36 year old gentleman

Delirium

Clinical scenario • A 36 year old gentleman was admitted following a road traffic accident, underwent surgery for fracture of femur shaft. • On the second day after the accident, in hospital, post operatively is referred for being agitated, restless, seeing large insects crawling on the wall • On examination tremulous, diaphoretic with tachycardia • Not oriented to time, place or person; incoherent speech

What is this patient displaying? • Delirium • Psychosis • Dementia • Depression with psychotic features

What is this patient displaying? • Delirium • Psychosis • Dementia • Depression with psychotic features

Delirium – clinical features • Disturbance in attention or cognition • Acute onset • Change from baseline • Fluctuating severity

Delirium - clinical features • Encephalopathy, acute brain failure, acute confusional state, and postoperative or ICU psychosis • Organic psychosis • Variegated manifestations however has a relatively acute decline in cognition, fluctuating over hours to days • Deficit of attention • memory, executive function, visuospatial tasks, and language • sleep-wake cycle, perception, affect changes and autonomic findings

Epidemiology • Hospitalised patients – 10 to 50% • More in elder and with hip surgery • Underdiagnosed • Higher rates in ICU and difficult to diagnose • Outside acute settings rates are lower • Significant morbidity and mortality

Risk factors • Age • Underlying cognitive dysfunction • Other predisposing factors – sensory deprivation, poor overall health, including baseline immobility, malnutrition, and underlying medical or neurologic illness, in hospital risks • Precipitating factors – infections, systemic illnesses, anesthetic agents, uncontrolled pain

Risk factors • 85 year old gentleman, living with grandson • History of being forgetful for over 2 years, progressive although fluctuating, increased food intake • Forgetting meals and conversations • At times not identifying people • Hard of hearing and vision impaired for past 3 -4 years; Malunited Colles, immature cataract, pallor

Pathogenesis • Cholinergic deficiency • Dopamine • “Stress” can unmask a deficient state

Approach • History, examination and MSE • Bedside clinical • Scales – physicians, nurses • CAM • All acutely confused patients should be presumed to be delirious • Sundowning may be present

Diagnosis • Essentially clinical diagnosis, bedside • Spectrum of manifestations, can fluctuate • Hypoactive (depressants like benzodiazepines) to hyperactive (DT) • Potentially reversible in most cases, contingent upon identification of the underlying cause • Most cases remit after a variable time, generally days to weeks • Persistence and chronicity implying etiology being addressed inadequately • Long term sequelae unknown, may cause neuronal damage and cognitive decline

History • Information - ? self, informant version • Baseline cognition, course of illness, medication or drug use • Any baseline cognitive impairment must be sought • Temporal evolution • Anticholinergic, sedative, alcohol, OTC, herbal • Toxin exposure

Physical exam • Signs of infection • Status of hydration • Jaundice, cyanosis, needle tracks • May miss the picture in morning rounds • Altered consciousness • If preserved, then assess attention • Toxins, infections, electrolytes, metabolic and endocrine conditions, seizures, cerebrovascular, autoimmune

Investigations • If history and exam unable to identify etiology then staggering investigations

Initial Evaluation • History with special attention to medications (including over-thecounter and herbals) • General physical examination and neurologic examination Complete blood count • Electrolyte panel including calcium, magnesium, phosphorus • Liver function tests, including albumin • Renal function tests

Further Evaluation Guided by Initial Evaluation • Systemic infection screen - Urinalysis and culture, Chest radiograph, Blood cultures • Electrocardiogram • Arterial blood gas • Serum and/or urine toxicology screen (perform earlier in young persons) • Brain imaging with MRI with diffusion and gadolinium (preferred) or CT; EEG • Suspected CNS infection or other inflammatory disorder: lumbar puncture after brain imaging

Second-tier Further Evaluation • Vitamin levels: B 12, folate, thiamine • Endocrinologic laboratories: thyroid-stimulating hormone (TSH) and free T 4; cortisol, Serum ammonia; Sedimentation rate • Autoimmune serologies: antinuclear antibodies (ANA), complement levels; p-ANCA, consider paraneoplastic/autoimmune encephalitis serologies • Infectious serologies: rapid plasmin reagin (RPR); fungal and viral serologies if high suspicion; HIV antibody • Lumbar puncture (if not already performed) Brain MRI with and without gadolinium (if not already performed)

Treatment • Underlying cause to be addressed • Supportive care – reorient with visible clocks, calendars and outsidefacing windows • Avoid any sensory deprivation • Sleep wake cycle, especially in ICU • Nutrition, volume status, pain • Home bedding, clothing and nightstand objects • Safety – self and others, alarms, restraints in exceptional cases

Prevent • Identify high-risk patients • Manage sleep, pain • Manage any infection • Correct any sensory deficit • Reorient pre-emptively in ICU

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