Download - Delirium-for Nurse, 2014
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DeliriumSurat Tanprawate, MD, FRCP(T), MSc(Lond.)
Division of NeurologyChiang Mai University
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What this talk will cover Denition
Risk factors
Causes
How to identify
How to treat
How to manage
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How common? Present in 10-15% of older adult hospital admissions
Occur in:
10-30% of hospitalised older adults
More than 50% of post-operative hospitalised patients
70-80% in ICU
Up to 60% of nursing home
1 year mortality rate is 35-40%
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Arousal and awareness, the two components of consciousness in coma,vegetative state, minimally conscious state, and locked-in syndrome.
arousal = !"#$% awareness = !"#&'(
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Delirium-the criteriaDSM-IV-TR Criteria
Disturbance of consciousness with reducedability to focus, sustain, or shift attention.
A change in cognition (memory decit,disorientation, language disturbance) or thedevelopment of a perceptual disturbance(i.e. auditory or visual hallucinations) that isnot better accounted for by a preexistingdementia.
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Delirium-the criteria
DSM-IV-TR Criteria, cont.
The disturbance develops over a short time(hours to days) and uctuates during the day.
There is evidence that the disturbance is caused
by the direct physiological consequences of ageneral medical condition or substance.
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Sleep-wake cycle disruption
Insomnia
Napping
Being awake at night
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Affective lability! Mood may fluctuate widely in a very
short period of time (minutes/hours)! Anxiety/panic/fear/anger! Apathy/sadness - commonly mistaken
for depression! Euphoria (esp. if steroid-induced)
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Differential diagnosis of
delirium Dementia with Behavioral Disturbance
Psychotic Disorder (Schizophrenia)
Mood Disorder (Depression, Mania)
Catatonia
Others
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Delirium subtypes Three subtypes by clinical
1. Hyperactive: features of this type of delirium includepsychomotor agitation, increased arousal and delusion.The degree of cognitive impairment may be variable andeven minimal in some instance.
2. Hypoactive: features of this type of delirium includewithdrawal, lethargy, and reduced arousal.
3. Mixed: characteristics of both hyperactive andhypoactive delirium
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DSM IV 1994
4 major subtypes by cause
Delirium due to a general medical condition
Substance induced delirium
Delirium due to multiple etiologies
Delirium not otherwise specied
American Psychiatric Association (1994) Diagnostic and Statistical Manual ofMental Disorders (4th Ed).Washington: American Psychiatric Association.
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When do they get it? -
acute illness
dehydration infection U&E disturbance
low O2, high CO2
heart failure liver failure renal failure CVA
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Red ag cause of deliriumUrgent recognition
Wernickes
Hypoxia
Hypoglycemia
Hypertensive encephalopathy
Intracerebral hemorrhage
Meningitis/encephalitis
Poisoning/medications
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Etiologies - I WATCH DEATH
! I = Infection
! W = W ithdrawal! A = A cute Metabolic! T = T rauma! C = C NS Pathology! H = H ypoxia
! D = Deficiencies(especially vitamin)
! E = Endocrinopathies! A = A cute Vascular! T = T oxins! H = H eavy metals
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A special note onmedications
They contribute up to 40% of cases
older people have decreased renal excretion and hepaticmetabolism
drugs of concern:
antipsychotics
anti-convulsants
corticosteroids
opiates
NSAIDS
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Why do we get it? Nobody really knows
Likely chemical imbalances caused by stress/ inammation/medications or combination thereof.
Best established neurotransmitter dysfunction: reducedcholinergic activity
Increased dopamine may also play a role
Low and excessive serotonin
Low and excessive GABA
Trzepacz and Meagher 2005
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practical evaluation
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How do we treat patient
Treat risk factors and precipitants !!!!
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Delirium management Monitor VS and I/O
Ensure good oxygenation
D/C nonessential medications
Minimize opioids, benzos, etc
Repeat PE, further lab, radiologic studies if causenot yet identied
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Delirium managementBehavioral/Environmental Strategies
Reorientation, calendars, clocks
Room near nursing station
Lights on/off during day/night
Windows
Family/familiarity
Hearing aids, glasses
Avoid restraints
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Delirium management! Pharmacological Therapy
! Nothing FDA-approved
! Antipsychotics are treatment of choice for
agitation compromising care or safety
! Haloperidol best studied, widely used
!
Virtually no anticholinergic effects! Virtually no hypotensive effects
! Risk of EPS (akathisia), rare with IV route
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Delirium management! Pharmacological Therapy
! Haloperidol! EPS rare when IV route used, however, IV
route carries risk of QTc prolongation ! riskof TdP
! Risk greatest with higher doses over shorter
periods of time, in pts with QTc >450! Monitor EKG and electrolytes (K, Mg)! Monitor for akathisia
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! Antipsychotic Dosing in Elderly!
Use clinical judgment depending on severity of symptoms for starting dose:! Haloperidol
! 0.5mg mild! 1mg moderate! 2mg severe
! Assess response to initial dose and repeat as needed, monitoring foreffectiveness and adverse effects
! Day one: order prn! Day two and beyond: assess total drug needed previous day and schedule
that amount over the next day. Reassess daily continuing process untildelirium resolves.
! Once symptoms have remitted, continue effective dose for 48 hours, thenslowly taper and discontinue over 1-5 days, depending on severity andduration of delirium up to that point. Avoid abrupt discontinuation after firstday or two of mental clarity to avoid risk of rebound symptoms
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Management of delirium
! Pharmacological Therapy! Benzodiazepines
! Primarily indicated in EtOH or benzodiazepinewithdrawal delirium
! Adjunct to neuroleptics in treatment of severeagitation
! Lorazepam preferred given its reliable
absorption from po/IM/IV routes! Generally avoided as may WORSEN
delirium-- especially hepatic encephalopathy
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Non-pharmacological encourage adequate uids
glasses, hearing aids
quiet rooms, well lit
re-orientation - clocks, calendars
personal items
encourage self-care and mobility
avoid frequent stafng changes
avoid catheters, iv lines
Guard/PCA/Companion
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How do we prevent it? Identify high risk patients
Do cognitive assessment as routine
reduce bad drugs
maintain adequate analgesia
maintain U&Es, Oxygenation, etc
try not to move patients
use the same nurse if possible
familiar things - pictures from home, clothes, books
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What you should remember
about delirium Confusion with altered Concentration + Consciousness Lots of Risk factors dementia and blindness
Look for and treat underlying causes Get history from family/friends
Avoid iv lines, catheters, changing rooms
Try familiar items, companions
Remember sedatives can make it worse!
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