Delirium

Key Points

• A confused older adult patient should generally be assumed to have delirium until proved otherwise.

• Delirium is a transient, global disorder of cognition and consciousness; changes in consciousness typically develop quickly and fluctuate during the day.

• Underlying dementia is a significant risk factor for delirium.

• The history, physical examination, and test results usually suggest a cause for delirium.

• Delirium is best managed by correction of the causative disturbances.

Delirium is a common problem encountered in patients seen by family physicians, especially in the hospital or skilled nursing facility. Delirium is characterized by a change in cognition and attention that develops rapidly, usually over hours to days, and fluctuates throughout the day. It may present as hyperactive delirium, with agitation, disorientation, and delusions; hypoactive delirium, demonstrated by the lethargic patient who is difficult to arouse and engage in conversation; or a mixed-type delirium with features of both. Hypo-active delirium is the most common encountered form of delirium, which may explain why it goes unrecognized in up to 70% of patients experiencing delirium (Gillis et al., 2006). Because of this, any confused older adult patient should generally be assumed to have delirium until proved otherwise. Delirium is a serious condition that has long-term ramifications, including increased hospital length of stay, increased mortality, failure to return to baseline cognitive and functional status, and increased need for prolonged, skilled nursing facility care. Box 42-5 summarizes risk factors for the development of delirium. Two thirds of delirium cases occur in patients with underlying dementia, placing these patients at significant risk when being treated for other health problems (Cole, 2004).

The mainstay of treatment for delirium is to identify and correct the underlying cause. This cause can usually be determined through a thorough history, physical examination, and evaluation of selected laboratory tests. Box 42-6

Box 42-5 Risk Factors for Development of Delirium

Age >65 years Chronic kidney disease Dehydration

Dependence with activities of daily living

Hearing impairment

Infection

Malnutrition

Multiple comorbid conditions Polypharmacy Underlying dementia Vision impairment

Box 42-6 Common Causes of delirium

Dehydration Electrolyte abnormalities Infection

Myocardial infarction Heart failure

Neurologic disorder (stroke, seizure) Hypoxia

Medications (anticholinergics, antihistamines, antidepressants, benzo-

diazepines, narcotics)

Intoxication

Environmental changes (change in location or caregiver, overstimulation) Pain

Sleep deprivation Surgery

Urinary catheter Urinary retention Fecal impaction summarizes some of the common causes that should be considered. Special attention should focus on recently started medications. Although almost any medication can precipitate delirium, analgesics, antiarrhythmics, antidepressants, Parkinson's medications, and anticholinergic medications such as antihistamines, benzodiazepines, p-blockers, calcium channel blockers, steroids, diuretics, clonidine, and digoxin are common culprits. A targeted laboratory evaluation should be undertaken, including a CBC, determination of electrolytes, BUN, creatinine, glucose, calcium, magnesium, phosphate, and liver function tests (LFTs). Oxygenation should be assessed by oximetry or arterial blood gases (ABGs). ECG should be considered, especially for patients with angina, dyspnea, or a cardiac history. A chest x-ray film and urinalysis to evaluate for occult infection, especially in older-adult patients, should also be considered.

If this evaluation does not elicit a likely cause for a patient's delirium, further testing may be necessary. Additional laboratory studies to consider include thyroid function tests, human immunodeficiency virus (HIV) testing, rapid plasma reagin (RPR) test, drug levels, toxicology screening, serum ammonia level, and serum vitamin B12 level. Lumbar puncture is usually reserved for patients with fever and signs suggesting meningitis. Neuroimaging may be indicated for patients with new neurologic signs or a history of head trauma. EEG may be helpful in the evaluation of patients with a suspected seizure disorder or to differentiate delirium from a functional psychiatric disorder.

Delirium can be treated with both nonpharmacologic and pharmacologic measures. Environmental modifications should be instituted early, before pharmacologic intervention or mechanical restraint is considered. A supportive and familiar environment should be created for the patient. Family members should be encouraged to remain nearby as much as possible. The staff should visit the patient frequently or move the patient to be near them. The room should be well illuminated, with a large, easily read clock and calendar. The family should bring familiar items from home to be placed in the patient's room. Whenever possible, normal sleep hygiene patterns should be maintained with minimal interruptions during the night hours.

Pharmacologic management of delirium should be considered when the previous treatments have failed to control agitation and should involve the use of antipsychotic medications. Among the antipsychotic agents, haloperidol (Haldol) at 1 to 2 mg orally every 4 hours as needed, or 0.25 to 0.5 mg orally every 4 hours for elderly patients, is recommended (American Psychiatric Association, 1999). Other antipsy-chotic medications, such as risperidone (Risperdal), 0.5 to 1 mg orally daily, and olanzapine (Zyprexa), 2.5 to 5 mg orally daily, may also be used; as yet, no RCTs have established the safety and effectiveness of one antipsychotic medication over another for the management of delirium symptoms (Seitz et al., 2007). Risperidone and olanzapine do not work as quickly as haloperidol, often require slow titration, and can be associated with significant orthostasis. More recent studies have also demonstrated a potentially elevated risk of mortality in older adults with dementia who were treated with atypical antipsychotics (Schneider et al., 2005). Therefore, these risks must be considered when initiating pharmacologic treatment for delirium. Further recommendations for initiating antipsychotics for the treatment of delirium include using the lowest possible doses, frequent reassessments to limit the duration of antipsychotic use, and a baseline ECG to rule out susceptibility to an arrhythmia from a prolonged QT interval (Seitz et al., 2007). Lorazepam (Ativan), a ben-zodiazepine, has also been used for the treatment of agitation associated with delirium, although a Cochrane review concluded that benzodiazepines cannot be recommended for the treatment of non-alcohol-related delirium (Lonergan et al., 2009). Physical restraints should be a last resort, reserved for the protection of patients who do not adequately respond to environmental and pharmacologic interventions.

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