Delirium

Delirium

David Ray Velez, MD

Table of Contents

Definitions
Risk Factors
Features and Complications
Evaluation
Prevention and Treatment

Definitions

Definitions

  • Delirium (DSM-5 Characteristics):
    • Disturbance in Awareness and Attention (Reduced Ability to Direct, Focus, Sustain, and Shift Attention)
    • Develops Over a Short Period of Time (Hours-Days), Represents a Change from Baseline, and Tends to Fluctuate Throughout the Day
    • An Additional Disturbance in Cognition is Present (Memory, Disorientation, Language, Visuospatial Ability, or Perception)
    • Caused by a Medical Condition, Intoxication, Substance Withdrawal, or Medication Side Effect
    • Not Better Explained by Another Neurocognitive Disorder
  • Postoperative Delirium: Delirium that Presents in the Postoperative Period
    • Emergence Delirium: Delirium in the Operating Room Immediately After Extubation
  • ICU Delirium: Delirium that Presents During a Stay in the ICU
  • Sundowning: Behavioral Deterioration During the Evening Hours
    • Most Common with Preexisting Dementia

Subtypes

  • Hypoactive Delirium: Somnolence and Psychomotor Retardation
  • Hyperactive Delirium: Agitation and Increased Psychomotor Activity
  • Mixed Delirium: Fluctuations Between the Two

Risk Factors

Patient Factors

  • Elderly
  • Preexisting Dementia – The Strongest Risk Factor in Elderly Patients
  • Malnutrition
  • ETOH Abuse
  • Medical Comorbidities
  • Psych Meds

Type of Surgery

  • 35% After Vascular Surgery
  • 40-60% After Hip Replacement

Severe Illness

  • Infection
  • Medications
  • Hypoxia
  • Electrolyte Abnormalities
  • Pain
  • Dehydration

ICU Factors

  • Bladder Catheter Use
  • Sensory or Functional Impairment
  • Physical Restraints
  • Sleep Deprivation
  • Unfamiliar Environment

Features and Complications

Common Associated Features

  • Psychomotor Behavioral Disturbances:
    • Hypoactivity
    • Hyperactivity with Increased Sympathetic Activity
    • Sleep Impairment
  • Variable Emotional Disturbances:
    • Fear
    • Depression
    • Euphoria
    • Perplexity

Incidence Varies Widely Between Studies

Complications

  • Delirium-Induced Persistent Cognitive Dysfunction Can Last for Months-Years
  • Can Accelerate the Cognitive Decline of Existing Dementia
  • Increased Morbidity and Mortality
    • 1-Month Mortality:
      • After a Single-Day of Delirium: 14.5%
      • After ≥ 3-Days of Delirium: 39%
    • 6-Month Mortality Increased 3.2-Fold
    • 12-Month Mortality Increases 10% Per Day of Delirium
  • Increased Length of Stay
  • Increased Rate of Discharge to Skilled Nursing Facility
  • Increased Rate of Readmission
  • Increased Cost

Evaluation

Confusion Assessment Method for ICU (CAM-ICU):

  • An Initial Evaluation to Assess for Delirium
  • High Sensitivity and Specificity
  • Can Even be Used in Ventilated Patients
  • Features:
    • Acute Onset and Fluctuating Course
    • Inattention
    • Disorganized Thinking
    • Altered Level of Consciousness
  • Delirium = Features 1 AND 2 + Either 3 OR 4

Evaluation of the Agitated Patient

Prevention and Treatment

Prevention/Treatment

  • Treat Underlying Medical Conditions
  • Appropriate Pain Control with Non-Opioid Medications
    • Avoid Opioids and Benzodiazepines
  • Frequent Reorientation
  • Allow Regular Visits from Family and Friends for Cognitive Stimulation
  • Support Physiologic Sleep Patterns
    • Avoid Unnecessary Nighttime Interruptions and Reduce Nighttime Noises
    • Avoid Excessive Daytime Sleeping
    • Provide Clocks and Keep Lights-On with Windows Open During the Day
  • Avoid Physical Restraints – Can Worsen Delirium
  • Early Mobilization with Physical Therapies
  • Ensure Vision and Hearing Aids are Accessible
  • May Require Use of a Bedside Sitter

Management of Agitation

  • *See Agitation
  • Initial Nonpharmacologic Attempts are Preferred
  • May Require Sedation if Violent or a Danger to Self/Others