dr annette downey consultant psychiatrist, exeter & cognitive analytic therapist mrcpsych...
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Dr Annette DowneyConsultant Psychiatrist, Exeter
& cognitive analytic therapistMRCPsych Course, Derriford
June 2011
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Definition• F05 Delirium, not induced by alcohol and other psychoactive
substances • An etiologically nonspecific organic cerebral syndrome characterized by
concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe. Includes: acute or subacute: · brain syndrome · confusional state (nonalcoholic) · infective psychosis · organic reaction · psycho-organic syndrome
• Excludes: delirium tremens, alcohol-induced or unspecified ( F10.4 ) F05.0 Delirium not superimposed on dementia, so described F05.1 Delirium superimposed on dementia Conditions meeting the above criteria but developing in the course of a dementia (F00-F03). F05.8 Other delirium Delirium of mixed origin F05.9 Delirium, unspecified
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Rates of Delirium
• 30% of hospital inpatients over the age of 65.
• At least 10% of unselected acute medical admissions in a typical UK hospital.
• Community prevalence of 1-2% – but 14% in the over 85s
• Usually under diagnosed and unrecognized by clinical staff
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Features for Diagnosis of Delirium
1 Disturbance of consciousness, with reduced ability to focus, sustain or shift attention
2 A change in cognition (memory/orientation/language) or the development of a perceptual disturbance that is not better accounted for by a pre existing /evolving dementia
3 The disturbance is over a short time (usually hours to days) & tends to fluctuate during the course of the day
4 There is evidence from the history, physical examination or lab findings of a direct physiological consequence of a general medical condition, substance intoxication or substance withdrawal.
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Historical Perspective
• Latin: ‘de’ – ‘out of’; lira – ‘the furrow’.• Old English – delire – to go astray, go wrong,
rave, to wander in mind or to go mad• Hippocrates 2500 years ago recognized a
clinical syndrome of symptomatic acute mental disorder associated with fever, which features cognitive & behavioural disturbance as well as sleep disruption, which improved when the fever improved.
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Clinical Types of Delirium
• Hyperactive (classical) or florid type – increased sympathetic activity – increased HR, sweating, dilated pupils flushed, increased BP; restless & seek reassurance. Keep other patients awake & high falls risk
• Hypoactive - poor oral intake, slumped over their tray, fall asleep mid-conversation – high risk of pressure sores, malnutrition & dehydration
• Mixed – fluctuates between the two – behaviour & sleep charts helpful – are often discharged too early
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Predisposing & precipitating Factors
• Usually multi-factorial (isn’t all of psychiatry?!)• The more factors the higher the risk
• Increased vulnerability mentally & physically• Age related• Dementia/cognitive impairment• Severity of illness• Metabolic/electrolyte imbalance eg dehydration,malnutrition.• Psychoactive medications – neuroleptics/narcotics/anticholinergics, more
than 3 medications added• Use of a bladder catheter• Previous delirium• Visual impairment• Male• Fractures on admission• Use of physical restraint
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Neuropathophysiology
• Neurotransmitters– Hypothesis of acetylcholine deficiency
• BUT – No cholinergic medication can prevent delirium - Is this a causal relationship?
• ALSO – other neurotransmitters have been implicated eg dopaminergic medications of Parkinsons, as well as dopamine antagonists eg haloperidol treating delirium
• WHAT about the role of serotonin – ‘The serotonin syndrome’? –seems the same as hyperkinetic delirium.
• OTHER neurotransmitters – Noradrenalin/ GABA/glutamate/Melatonin; or a neurotransmitter balance?
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Glucocorticoids
• Hypothalamo-pituitary Axis• The bodies reaction to physical illness is to
produce glucocorticosteroids• The hippocampus has high numbers of
receptors• Hypercortisolism is demonstrated in delirium
assoc with LRTI/ Post op delirium/post stroke delirium
• BUT most patients with delirium have normal not supressed cortisol levels.
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Cytokines
• Interleukin-2 therapy causes delirium & this is dose dependent
• Mechanism?
Christ in the Storm, Rembrandt
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Other Types of Delirium
• Delirium tremens
• Benzodiazepine withdrawal
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Patient Experience
• ‘I was certainly paranoid in the ICU [delirious I suppose], I was absolutely sure [still am] that an ICU nurse tried to kill me to sell my organs on ebay - heard the whole conversation whilst he was sedating me with serious drugs as I kept ripping ouy my central and trach...’
• ‘When I was in ICU, after waking-up from a drug-induced coma, I thought I was being held hostage in some kind of medical lab! I had soft restraints on my hands and I remember using my foot to try to pull a machine closer to the bed because I thought I would be able to send out an "email S.O.S." - I am sure it was an ultrasound machine or ECG machine.’
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June 201113
Delirium Presents With:Delirium Presents With:
• Sudden onset• Poor concentration/attention (WORLD)• Global impairment of time, place and person,
recent memory, and slowed thinking.• Psychomotor disturbance – either reduced or
agitated• Disturbed sleeping pattern – eg up all night• Emotional lability• Hallucinations – often visual and complex
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Confusion Assessment method (CAM) for Delirium
Inouye, S. Ann Int Med 1990;113:941-948.Criteria:• 1. Acute change in mental status, • AND Observation by a family member, caregiver, or primary care physician• 2. Symptoms that fluctuate over minutes or hours, • AND Observation by nursing staff or other caregiver• 3. Inattention -Patient history, Poor digit recall, inability to recite months of
year backwards• PLUS4. Altered level of consciousness, • OR Hyper-alertness, drowsiness, stupor, or coma• 5. Disorganized thinking, Rambling or incoherent speech
• The first 3 criteria PLUS the fourth OR the fifth criterion must be present to confirm a diagnosis of delirium.
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Video demonstration of the CAM method
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June 201116
Delirium DifferentialDelirium Differential• Depression (pseudodementia) • Dementia (chronic confusion)• Motor slowness (Parkinsons /ism) • General physical frailty• Learning disability• Dissociative states/personality
(pseudodementia also).• Impoverished Social Environment• Iatrogenic (eg secondary to medication)• Cognitive Impairment not dementia
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June 2011Annette Downey
Differentiating: Differentiating: Delirium Delirium and Dementiaand Dementia
• Acute often at night• Fluctuates with lucid
periods• Lasts hours /days• Reduced awareness• Impaired attention• Disorientated for time• Visual illusions and
hallucinations• Disrupted sleep
• Insidious onset• Stable over a day• Lasts months/years• Clear awareness• Good Attention• Disorientation in later
stages• Impoverished thinking• Sleep is usually normal
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Causes of Delirium
• Infection• Stroke• Drugs• MI• Fractures• Carcinoma• Electrolytes• Heart failure• Diabetes
• Peripheral vascular disease/gangrene
• Alcohol withdrawal• GI bleed• Respiratory failure• PE• Anaemia• Perforated DU• Subdural• Brain tumour
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June 2011Annette Downey
Management begins with Management begins with obtaining a full historyobtaining a full history
• Informant History – relatives & carers for baseline status
• Record chronological progression• Wide symptom variation• Length of symptoms• Insidious or rapid onset• Gradual or stepwise progression• Day to day fluctuations• Describe a typical day• Consider effect of symptoms on function
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Initial Clinical management
• Establish baseline status• Medical investigations – FBC, glucose, urea,
electrolytes, Ca, LFTs, TFTs, inflammatory markers, urine dipstick, +/-MSU
• Blood cultures indicated?• ABG/ CXR/ ECG• Rectal examination?• Prompt rehydration/antibiotics & O2• SC fluids may be a good idea• Are medications being taken or discarded?• Accurate fluid & nutritional charting• Watch out for pressure sores/pneumonia/DVTs
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Supportive & behavioural management
• Appropriate lighting levels for the time of day
• Regular & repeated cues to orientation
• Clocks/calandars• Hearing aids/spectacles• Continuity of care from nursing
staff• Encourage mobility & activity• Approach & handle gently• Turn off noisy alarms etc• Analgesia regularly• Warm milky drinks, relative
quiet & single cubicle if poss
• Encourage family visits• Explain the confusion to family• Fluid & food intake• Adequate CNS oxygen
delivery (sats above 95%)• Sleep hygeine• Avoid ward & hospital transfers• Avoid physical restraint• Rx constipation• Avoid anticholinergics• Avoid catheters where poss
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Medication
• Review the ongoing need for repeat prescriptions
• Consider omitting respiridone, olanzapine/ quetiapine.
• Do Not Stop AChEIs such as donepezil, rivastigmine, galantamine
• Scrutinize opiates – tramadol• Follow your local hospital guidelines for the use
of prn sedative medications ie rapid tranquilization policy for mental health trusts.
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June 2011Annette Downey
Medical treatmentMedical treatmentThere is not much research to support clinical There is not much research to support clinical
practicepractice• Haloperidol PO 0.5 mg
at 2 hourly intervals (max of 5 mg per day) or IM 1-2 mg
• Anxiolytics especially for lewy body dementia & patients with parkinsons
–lorazepam PO 0.5-1mg (max 3 mg per day)
-clonazepam
• Avoid polypharmacy• Side effects are
common• Titrate slowly and
monitor carefully• Dosette boxes and
blister packs very helpful in agreement with carers
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Communication
• Frightening confusing experience for patients• Use lucid periods opportunistically• Warn that it might recur & advise early attendance at GP
surgery• With relatives/carers – family meetings on the ward –
again opportunistically– Initially information gathering– Then education/explanation
about deliriumHelp with orientation – photos, assist at meal times, playing card games, talking about past times.Discussing the future
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Prognosis
• Delirium is a marker for physical & cognitive decline
• It is an independent risk factor for poorer outcomes following admission
• There is a trend to longer inpatient stays• Increased risk of falls, pressure sores, urinary
incontinence• Higher readmission rates• Increased long term institutionalism• Increased mortality
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June 2011Annette DowneyAdopt A Person Centred Approach
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June 2011Annette Downey
• Each person has a unique life history, set of relationships and preferences
• The persons actions are not under their control
• Important to avoid getting angry and frustrated; avoid challenging the person.