Delirium/Deliria All answers are from APA Practice Guideline AJP May 1999 Supplement, DSM-IV-TR, and Delirium Guideline Watch, at www.psych.org

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As of 28Jul06. Next revision due May 9, 2007

Delirium - criteria Q. Basic criteria of “delirium”?

Delirium - criteria Ans. 1. Disturbance of consciousness 2. Disturbance of cognition 3. Disturbance develops over a period of hours to days 4. Disturbance fluctuates during the course of a day 5. Evidence that disturbance is result physiological consequences of a general medical condition, a substance or withdrawal from a substance

Differ from dementia Q. How does dementia differ from delirium?

Diff from dementia Ans.

While they both have memory deficits, pts with dementia are/have: -- alert -- no consciousness deficits -- no arousal deficits -- slow onset of condition -- little change over the course of a day.

Communications Q. What four communication psychopathologies are common in delirium?

Communications Ans.

1] aphasia 2] dysarthria 3] dysnomia 4] dysgraphia

memory Q. Which memory impairment is most common?

Ans. Recent.

memory

Neurological abnormalities in Li intoxication Q. Neurological abnormalities in Li intoxication include?

Neurological abnormalities in Li intoxication Ans. 1] cerebella signs 2] myoclonus 3] hyper-reflexia

Orientation Q. Which disorientation is rare?

Ans. To self.

Orientation

EEG Q. EEG findings in delirium?

EEG Ans.

Usually generalized slowing, but there is a major exception asked for in the next slide.

EEG - exception Q. What is the exception to generalized slowing?

EEG - exception Ans. Delirium associated with alcohol and other sedatives where one sees generalized fast activity

Age prevalence Q. Which age groups is delirium common?

Prevalence – age groups Ans. Children and the elderly.

Elderly - gender Q. Which gender more frequently suffers from delirium?

Ans. Men.

Elderly - gender

Prevalence - hospitals Q. Prevalence of delirium on the medical and surgical wards of hospitals?

Prevalence - hospitals Ans. 10 – 30%.

Terminal illness Q. Percentage of terminally ill who become delirious?

Terminally ill Ans. Up to 80%.

Mortality Q. Mortality of elderly who are hospitalized and develop delirium?

Mortality Ans. Up to 20-75%.

[Obviously, this is too broad to easily be the answered, but this range does give one a sense of the correct answer as one weighs the other factors in the examiner’s question.]

Delirium differential Q. What are the four major categories of illnesses/disorders that are associated with delirium?

Delirium differential Ans.

1. General medical conditions.

2. Substances intoxication or withdrawal 3. Medications.

4. Toxic exposures

Hypoglycemia Q. Pt delirious and hypoglycemia suspected. What is the treatment?

Hypoglycemia Ans. 1. Finger stick 2. Thiamine 100 mg IV before glucose 3. 50 ml IV of 50% glucose solution

Hypoxia Q. Delirious and hypoxia suggestive, what to do?

Ans. O2 Hypoxia

Hyperthermia Q. Delirious and temp above 105 F, what to do?

Hyperthermia Ans. Rapid cooling.

Hypertensive Q. Delirious and hypertensive with BP of 160/150, what to do?

Hypertension Ans. Guideline only says “prompt antihypertensive treatment.” Merck Manual, p 618, lists nine possible meds to considering using -- after getting the pt to an ICU with goal of decreasing BP 25%/hour.

Wernicke’s Q. Treatment of Wernicke’s?

Wernicke’s Ans. 100 mg thiamine IV, followed by same daily p.o.

Malnutrition Q. Delirium associated with malnutrition should be given?

Malnutrition Ans. B vitamins.

Sedative/alcohol withdrawal Q. Management of sedative/alcohol withdrawal delirium?

Sedative/alcohol withdrawal Ans. 1] Benzodiazepines 2] thiamine IV 3] glucose IV 4] magnesium 5] phosphates, and 6] folate and other B vitamins

Anticholinergic Q. Delirious from anticholinergic meds. What to do?

Anticholinergic Ans. 1. Withdraw meds.

2. Physostigmine

Physostigmine Q. What is action of physostigmine?

physostigmine Ans. Cholinesterase inhibitor.

Physostigmine side effects Q. Side effects of physostigmine?

Physostigmine – side effects Ans.

1. Bradycardia 2. Nausea and vomiting 3. Salivation 4. Increased gastric acid.

5. Seizures

Physostigmine - doses Q. Doses of physostigmine?

Physostigmine - doses Ans. IV or IM: 0.5 to 2.0 mg

Environment Q. What are some environmental interventions that are useful in managing delirium?

Environment Ans. 1. Changing the lighting to cue day and nights.

2. Moderate level of stimulation, either too much or too little can worsen delirium.

3. Correcting visual or auditory impairment, if present, e.g., retrieve glasses.

4. Have familiar objects and people present.

Clinician communications Q. Clinician communications with delirious pts should include?

Clinician communications Ans.

Statements that orient the pt to person, place, time, and circumstances.

Statements reassuring the pt that the deficits they are experiencing are common and usually temporary.

Antipsychotics Q. Preferred antipsychotic is?

Antipsychotics Ans. Haloperidol.

Haloperidol oral dosing Q. Typical dosing of haloperidol in pts with delirium?

Haloperidol - oral dosing Q. 1 -2 mg / 2 – 4 hours in young folks 0.25 – 0.50 / 2 – 4 hours in elderly

Haloperidol IV monitoring Q. If IV dosing, what to monitor? Why?

Haloperidol IV monitoring Ans. EKG looking for QTc intervals.

QTc Q. In monitoring the QTc, under what circumstances would you consider a cardiac consultation and IV haloperidol discontinuance?

QTc Ans. Either: 1] > 450 msec Or 2] 25% increase over baseline.

Benzodiazepines Q. What disorders/illnesses with delirium do you use benzodiazepines?

Benzodiazepines Ans. 1] Delirium associated with seizures.

2] Delirium associated with sedative/alcohol withdrawal.

Benzodiazepine preference Q. Among the benzodiazepines, which would you select? Why?

Benzodiazepine preference Ans. Practice Guideline likes lorazepam because no metabolites and short acting.

Combination Q. When would you combine haloperidol and lorazepam?

Combination Ans. Pt seems intolerant of large doses of haloperidol, so you use small or moderate levels and add some lorazepam.

Combination dosing Q. If using both haloperidol and lorazepam IV, what might be a typical dose of each?

Combination dosing Ans. 1] Haloperidol 3 mg IV followed by 2] 0.5 to 1.0 mg IV of lorazepam.

Droperidol Q. What are some advantages of droperidol in comparison to haloperidol?

Droperidol Ans. 1] more rapid onset 2] grater sedation – when needed 3] shorter half-life.

Droperidol - monitoring Q. What to monitor if using droperidol?

Droperidol - monitoring Ans. EKG with focus on QTc.

Opioids Q. When might opioids be used in the delirious pt?

Opioids Ans. When pain is contributing to the delirium.

ECT Q. When might ECT be used with the delirious pt?

ECT Ans. Delirium secondary to NMS.