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http://epilepsy.kku.ac.th29 ��3!��� 2550

Topics�Epidemiology

�Diagnostic criteria

�Prevention and management

�Delirium tremens

Objectives

�Improve an indicator of the quality of health care

Definition Delirium is an acute confusional state

Dementia is an chronic confusional state

Delirium

�Acute brain failure

�Confusional state

�Post-operative psychosis

Epidemiology : Prevalence �Community 1-2 %�Hospital admission 14-24%�Older postoperative 15-53%�Nursing home 60%�ICU 70-87%�End of life 83%

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Impact of delirium

�Prolong length of stay

�Re-intubation

�Higher mortality at admission and 6,12 months

�Increase cost of care

Clinical feature of delirium �Acute onset �Fluctuating course � Inattention �Disorganized thinking�Altered level of consciousness, sleep 3 wake cycle �Cognitive deficit � Illusion or hallucination �Hyperactive/hypoactive �Emotional disturbance

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Pathogenesis �Generalized disruption in higher cortical function

�Neurotransmission, inflammation, chronic stress

�Cholinergic deficiency

�Dopaminergic excess

�Chronic hypercortisolism

Delirium : types

1. Hyperactive

2. Hypoactive

3. Mixed

Predisposing factors �Age , Male �Cognitive impairment �Functional status �Visual/hearing impairment�Decrease intake �Drug, alcohol �Medical condition

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Risk factors for delirium

�Dementia OR 2.3

�Vision impairment OR 2.1

�Functional impairment OR 1.7

�High co-morbidity OR 1.7

�Restrains OR 3.2

Arch Intern Med 2007;167:1406-13

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:A\I?H89]RT[H^S delirium

DiphenhydramineTriprolidine (Actifed)Chlorpheniramine(Piriton)Promethazine(Phenergan)

Benzodiazepines Narcotics Anti-parkinsonianagents (L-dopa)NSAIDs

CimetidinePrednisoloneTheophyllineTCA(amitriptyline)

Over the counter drugs

Other drugs associated with delirium

Drugs with high anticholinergicactivity

:A\I?H89]RT[H^S delirium

Anti-diarrhea agents

IBS drugs

Furosemide

Hyposcine(Buscopan)

Laxatives

Antibiotics

Haloperidol

Digoxin

Nifedipine

Anti-psychotics (chlorpromazine)

Ranitidine

Over the counter drugs

Other drugs associated with delirium

Drugs with high anticholinergicactivity

Causes of acute confusional stateWithdrawal syndromes

Alcohol Drugs

CNS infections

Meningitis Encephalitis

Intracranial lesions

Head trauma

Acute lesions

Subdural hematoma

Systematic illnesses

Sepsis (septic encephalopathy)

Acute uremia Hepatic failure

Cardiac failure Pulmonary disease

Electrolyte disturbances

Hypocalcaemia

Porphyria

Carcinoid syndrome

Causes of acute confusional stateHypertensive encephalopathy

Miscellaneous

Head trauma

Sleep deprivation

Psychiatric disorders

Mania (esp. in the elderly)

Schizophrenia

Depression

Endocrinopathies

Thyroid dysfunction

Parathyroid tumors

Adrenal Pituitary dysfunction

Nutritional deficiencies

Wernicke|s encephalopathy

Niacin Vitamin B12

Folate

Causes of acute confusional state

Intoxications

Drugs (esp. anticholinergics in elderly)

Alcohols

Metals

Industrial agents

Biocides

Metabolic encephalopathiesEndocrinopathies

Acute adrenal failure

Pituitary apoplexy

Vital organ failure

Hepatic encephalopathy

Acute hepatic failure

Chronic hepatic failure

Uremia

Acute renal failure

Chronic renal failure

Fluid and electrolyte disorders

Hyponatremia

Hypernatremia

Hypocalcemia

Hypercalcemia

Hypomagnesemia

Hypermagnesemia

Hypophosphatemia

Hypocapnia

hypercapnia

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Metabolic encephalopathies

Complications of treatment Pancreatic encephalopathy Hereditary metabolic disorders Porphyria

Mitochondrial disorders

MELAS

Leigh disease

EndocrinopathiesThyroid disorders Myxedema (hypothyroidism)Hyperthyroidism

Hashimoto|s thyroiditis

Hypoglycemia

Hyperglycemia

Aetiology

�Organic aetiology identified in 95%

�D I M T O P

�Multifactorial in origin�Organic factors

�Psychosocial stressors

�Unfamiliar surroundings

�Excessive or diminished sensory input

D I M T O P

�D-Drugs

�I-Infection

�M-Metabolic

�T-Trauma / Toxins

�O-Oxygen deficits

�P-Psychological/post-ictal

Treatment

�Specific measures�Identify and treat the underlying condition

�Thorough medical history, physical and neurological examination, lab tests

Treatment

�General measures�Ensure sleep

�Maintain fluid and nutritional state

�Provide support and nursing care

�Rest in a quiet, well-lit

�Maintain orientation

�Sedate the agitated, fearful patient

Awareness of occult or atypical presentation

�Myocardial infarction �Infection, URI, UTL�Respiratory failure �UGI 3 bleeding�Hematuria�Incontinence/constipation

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The Yale Delirium Prevention �Orientation and therapeutic activity �Non-pharmacological approach �Prevent sleep deprivation�Communication method �Prevent volume depletion �Early mobilization

Pharmacologic treatment �Antipsychotic

�Atypical antipsychotic

�Benzodiazepine

�Antidepressant

Antipsychotic : haloperidol �First line drug

�0.5-1.0 mg twice daily, oral

�1 mg im, repated dose after 30-60 min

�Avoid iv

�Aware : QT prolong, NMS

Atypical antipsychotic �Risperidone

�0.5 mg twice daily

�Less side effect

�Olanzapine 2.5-5 mg once daily

�Quetiapine 25 mg twice daily

Benzodiazepine

�Lorazepam

�0.5 3 1 mg, oral

�Reserve for PD, alcoholic withdraws, NMS

Bright light therapy on post-operative

� Light intensity 5000 lx, 100 cm distance

� Significant reduce delirium score on day 3

� Earlier ambulation 2 days

Intensive Crit Care Nurs 2007 Aug 8

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Alcohol Withdrawal Syndrome

1. Tremulousness and associated symptoms

2. Hallucination

3. Withdrawal seizures �Rum Fits�

4. Delirium tremens

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� BT 40OC, RR 28/min, PR 120/min, BP 150/90 mmHg

� Rigidity all extremities, stiffness of neck all direction

� Comatose consciousness

��6�7��, Alteration of ConsciousnessStrokec

complicationCNS infection Systemic infection

Metabolic &ToxicEncephalopathy

Other mass lesioneg. CSH, tumor

Fever, DeliriumRigidity,Coma

4 main causes

Precipitating factors Disease Complication

1. Stress

2. Infection

3. Infection

4. Drug

5. Psychosomatic symptoms

MetabolicDecerebrateInfection

ICP

Metabolic

ICPMetabolic Sepsis

Encephalopathy

Stroke

EncephalitisSeptic encephalopathy

Systemic Infection

Mass lesion

Drug/Toxin

Differential Diagnosis

�CNS infection

�Tetanus

�Neuroleptic Malignant Syndrome� Idiosyncratic, high fever, rigidity, tachycardia, rhabdomyolysis, onset over days to weeks, trigger by drugs that block central dopaminergic pathways, lithium, phenothiazine, halloperidol, metochopramide, discontinution of levodopa

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Differential Diagnosis

�Malignant hyperthermia

�AD, GA with halothane or succinyl choline, fever, rhabdomyolysis

�Catatonia

�Hypothalamic tumor

Physical examination and investigation

�Wound

�Drug

�Baseline lab, CBC(leucocytosis), CPK

�Neuro imaging, CT, MRI

�Lumbar puncture

Take Home Message�Fever, conscious change, rigidity

�History of anti-psychotic drug used

�Elevated CPK NMS

�Stop medication

�Start bromocriptine

�Supportive treatment

Thank you for your interest