Delirium

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Key diagnostic features of the CAM
- Acute change in mental status that fluctuates
- Abnormal attention and either disorganized thinking or altered level of consciousness
Several nondiagnostic symptoms may be present:
- Short- and long-term memory problems
- Sleep-wake cycle disturbances
- Hallucinations and/or delusions
- Emotional lability
- Tremors and asterixis
Subtypes based on level of consciousness
- Hyperactive delirium (15%): patients are loud, agitated, and disruptive.
- Hypoactive delirium (20%): quietly confused; sleepy, may sit and not eat, drink, or move
- Mixed delirium (50%): features of both hyperactive and hypoactive delirium
- Normal consciousness delirium (15%): still displays disorganized thinking, along with acute onset, inattention, and fluctuation

HISTORY

Time course of mental status changes
Recent medication changes
Symptoms of infection
New neurologic signs
Abrupt change in functional ability

PHYSICAL EXAM

Comprehensive cardiorespiratory exam is essential.
Focal neurologic signs are usually absent.
Mini mental state exam (MMSE) is the most well known and studied cognitive screen, but it may not be the most appropriate in an acute care setting; shorter cognitive screens have been studied in delirious patients (i.e., short blessed test [SBT], Brief Alzheimer's Screen [BAS], and Ottawa 3DY) and may be helpful if performed serially over time. Most patients will perform poorly if delirium is present; dementia cannot be diagnosed during delirium.
GI/GU exam for constipation/urinary retention

DIFFERENTIAL DIAGNOSIS

Depression (slow onset, disturbance of mood, normal level of consciousness, fluctuates weeks to months)
Dementia (insidious onset, memory problems, normal level of consciousness, fluctuates days to weeks)
Psychosis (rarely sudden onset in older adults)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Guided by history and physical exam
- CBC with differential
- Comprehensive metabolic panel (CMP)
- Urinalysis, urine culture, blood culture
- Medication levels (digoxin, theophylline, antiepileptics where applicable)
Chest radiograph for most
ECG as necessary
Others, if indicated by history and exam

Follow-Up Tests & Special Considerations

If lab tests listed above do not indicate a precipitator of delirium, consider
- Arterial blood gases
- Troponin
- Toxicology screen
- Ammonia
- Thyroid-stimulating hormone
Noncontrast-enhanced head CT scan if
- Unclear diagnosis
- Recent fall
- Receiving anticoagulants
- New focal neurologic signs
- Need to rule out intracranial mass before lumbar puncture

Diagnostic Procedures/Other

Lumbar puncture (rarely necessary)
- Perform if clinical suspicion of a CNS bleed or infection is high.
EEG (rarely necessary)
- Consider after above evaluation if cause remains unclear or suspicion of seizure activity.

TREATMENT

The best treatment is prevention (4)[A].
Addressing six risk factors (i.e., cognitive impairment, sleep deprivation, dehydration, immobility, vision impairment, and hearing impairment) in at-risk hospitalized patients can reduce the incidence of delirium by 33%.
Principles: Maintain safety, identify causes, and manage symptoms.
Stabilize vital signs and ensure immediate evaluation.

GENERAL MEASURES

Postoperative patients should be monitored and treated for
- Myocardial infarction/ischemia
- Infection (i.e., pneumonia, UTI)
- Pulmonary embolism
- Urinary or stool retention (attempt catheter removal by postoperative day 2)
Anesthesia route (general vs. epidural) does not affect the risk of delirium.
ICU sedation-avoidance of benzodiazepines may reduce risk (5)[B].
Multifactorial treatment: identify contributing factors and provide preemptive care to avoid iatrogenic problems, with special attention to
- CNS oxygen delivery (attempt to attain):
  - SaO2>90% with goal of SaO2>95%
  - Systolic BP <2/3 of baseline or >90 mm Hg
  - Hematocrit >30%
Fluid/electrolyte balance
- Sodium, potassium, and glucose normal (glucose <300 mg/dL in diabetics)
- Treat fluid overload or dehydration.
Treat pain
- Schedule acetaminophen (650 mg QID) if daily pain
- Opioids alone (morphine) or in combination (oxycodone, hydrocodone) may be used for breakthrough pain.

ALERT

Avoid meperidine (Demerol).
Eliminate unnecessary medications.
- Investigate new symptoms as potential medication side effects (i.e., Beers medications).
Regulate bowel/bladder function.
- Bowel movement at least every 48 hours
- Screen for urinary retention.
Prevent major hospital-acquired problems.
- 6-inch thick foam mattress overlay or a pressure-reducing mattress
- Avoid urinary catheter.
- Incentive spirometry
- Venous thromboembolism (VTE) prophylaxis if bed-fast
- Early mobilization
- Environmental stimulation
  - Glasses and hearing aids
  - Clock and calendar
  - Soft lighting
  - Music and television, if desired
- Sleep
  - Quiet environment
  - Soft music
  - Therapeutic massage
Restraints increase risk of falls/injury
- Use only in the most difficult-to-manage patients, as briefly as possible

MEDICATION

Nonpharmacologic approaches are preferred for initial treatment, but medication may be needed for agitation management, especially in the ICU setting (6)[C].
Medications treat only the symptoms and do not address the underlying cause.
No medication is FDA approved for delirium.
Medications should not be used prophylactically.

First Line

Antipsychotics
- Haloperidol (Haldol): initially, 0.25 to 0.5 mg PO/IM; reevaluate and potentially redose hourly. Critical care guidelines do not support use of antipsychotics for prevention of ICU delirium (5).
- Quetiapine (Seroquel) 12.5 to 25 mg PO BID
- Risperidone (Risperdal) 0.25 to 0.5 mg/day PO
Benzodiazepines should be avoided except in alcohol withdrawal or if patient taking at baseline because delirium could be a sign of withdrawal.
Lorazepam (Ativan): initially, 0.25 to 0.5 mg PO/IM/IV q6-8h; may need to adjust to effect (caution in patients with impaired liver function)
Contraindications: Avoid typical antipsychotics in patients with Parkinsonism or Parkinson disease.
Precautions: Typical antipsychotics may cause extrapyramidal effects; benzodiazepines may cause delirium. Both increase fall risk. Antipsychotics may prolong the QT interval.

Second Line

Olanzapine (Zyprexa) 2.5 to 5.0 mg/day PO
Multiple trials demonstrate adverse events with cholinesterase inhibitors in the management of delirium; evidence does not support their use.

ISSUES FOR REFERRAL

Geriatric, psychiatric, or neurologic consultation is helpful if delirium is not easily explainable or resolving after full evaluation. Interprofessional team approach is best.

ADDITIONAL THERAPIES

Early mobilization critical

Out of bed several hours daily starting on hospital day 2 (or postoperative day 1) if no contraindications
Daily therapy if not ambulating or functioning independently

INPATIENT CONSIDERATIONS

General measures described earlier are also applicable to delirium prevention.
Admission Criteria/Initial Stabilization
New delirium is a medical emergency and requires admission, except in the setting of palliative home care.
IV Fluids
As needed for dehydration
Nursing

Screen for development of delirium.
Assessment of precipitants/contributing factors ( pain, constipation, urinary retention)
Reorient; maintain day/night orientation.
Institute skin care program and turning regimen for immobile patients.
Maintain and encourage mobility.
Encourage family presence and participation.

Discharge Criteria

Resolution of precipitating factor(s)
Safe discharge site if delirium is slow to resolve

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

If delirium at discharge, often needs postacute facility and ongoing assessment for resolution
If no delirium at discharge and going home, follow-up with primary care physician in 1 to 2 weeks

Patient Monitoring

Evaluate and assess mental status daily.
Continued evaluation for precipitating cause(s)

DIET

Liberalize diet to increase oral intake
Nutritional supplements (1 to 3 cans/day) if intake poor
Consider temporary nasogastric tube if unable to eat and bowels working.

PROGNOSIS

May take weeks/months to fully resolve
Usually improves with treatment of underlying condition(s); can lead to chronic cognitive impairment
Delirium significantly increases a person's chance of dying even up to 1 year later.

COMPLICATIONS

Falls
Pressure ulcers
Malnutrition
Functional decline
Future cognitive dysfunction
Higher risk for institutionalization
Death

REFERENCES

11 Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922.22 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.33 van Eijk MM, van Marum RJ, Klijn IA, et al. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med. 2009;37(6):1881-1885.44 Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375-380.55 Kalabalik J, Brunetti L, El-Srougy R. Intensive care unit delirium: a review of the literature. J Pharm Pract. 2014;27(2):195-207.66 Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

ADDITIONAL READING

Inouye SK, Robinson T, Blaum C, et al. Amercian Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142-150.
National Clinical Guideline Centre. Delirium: Diagnosis, Prevention, and Management. London, United Kingdom: National Clinical Guideline Centre; 2010.
Quinlan N, Marcantonio ER, Inouye SK, et al. Vulnerability: the crossroads of frailty and delirium. J Am Geriatr Soc. 2011;59(Suppl 2):S262-S268.

CODES

ICD10

R41.0 Disorientation, unspecified
F19.931 Oth psychoactive substance use, unsp w withdrawal delirium
F10.231 Alcohol dependence with withdrawal delirium
F05 Delirium due to known physiological condition

ICD9

780.09 Other alteration of consciousness
292.81 Drug-induced delirium
291.0 Alcohol withdrawal delirium
290.3 Senile dementia with delirium
290.0 Senile dementia, uncomplicated
293.9 Unspecified transient mental disorder in conditions classified elsewhere
293.1 Subacute delirium
293.0 Delirium due to conditions classified elsewhere

SNOMED

2776000 Delirium (disorder)
191492000 Drug-induced delirium (disorder)
8635005 alcohol withdrawal delirium (disorder)
191461002 Senile dementia with delirium
231450007 psychosis associated with intensive care (disorder)

CLINICAL PEARLS

The CAM criteria for delirium are acute onset of fluctuating mental status, inattention, and either disorganized thinking or altered level of consciousness.
Hypoactive subtype of delirium can easily be missed.
Addressing six risk factors (i.e., cognitive impairment, sleep deprivation, dehydration, immobility, vision impairment, and hearing impairment) in hospitalized patients can reduce the incidence of delirium by 33%.
Delirium may not resolve as soon as the treatable contributors resolve; may take weeks or months
Avoid diphenhydramine and benzodiazepines in older patients. Nonpharmacologic measures are preferable as a sleep aid.

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