Delirium and Hospitalization Risks
Increase risk for death in hospital, nosocomial complication, post-acute nursing home placement, poor functional recovery
Delirium
Characteristics
-Acute change in mental status and fluctuating course
-Inattention
PLUS either disorganized thinking or altered LOC
Delirium
Screening
Confusion Assessment Method (CAM) tool
Delirium
DSM–V Criteria
- Disturbance in attention and focus
- Change in cognition not the result of existing or evolving neurocognitive disorder or prolonged state of decreased arousal (coma)
- Develops over short time, fluctuates throughout the day
- Evidence that it has developed as the result of a physiological condition
Delirium
Subtypes
- Hyperactive/agitated delirium:
- Hypoactive delirium: less recognized
- Mixed
Delirium
Etiology
- Decrease ACh in brain d/t increase in anticholinergic activity
- Serotonin, dopamine, GABA alterations
Role of acetylcholine (ACh)
-Electrical stimulation, neuromuscular junction, innervated organs, parasympathetic system
Anticholinergic side effects
- Pupillary dilation, blurred vision, decreased secretions, urinary retention, constipation, impaired concentration, confusion, attention deficit
- Results from decreased cholinergic activity
Postoperative Delirium
Characteristics
- Peaks on 2nd postoperative day
- R/F: cognitive impairment, physical function alterations, hx of alcohol abuse, age, abnormal chemistries
- Associated with opioids, benzos, anemia, pain
Postoperative Delirium
Prevention
- Associated with opioids, benzos, anemia, pain
- Provide limited sedation, appropriate analgesia, transfuse high-risk patients
Delirium
Management
- Delirium Onset: Minimize drugs that may contribute
- Behavioral: social restraints, remind, redirect, family in room
Delirium
Prevention
- Treat underling disease and contributing factors
- Remove catheters
- Manage constipation and urinary retention
- Proper sleep
- Avoid sedatives
- Optimize medications
Delirium
Assessment
History: time course, associated symptoms, review meds, drugs, alcohol use
PE: VS, O2, Mental status, gen PE
Delirium
Diagnostics?
CBC, CMP, renal function, UA, LFTs, serum drug levels, ABG, CXR, EKG, pan-C&S
Delirium
Pharmacological Management
Haloperidol
Mild: 0.25-0.5mg PO or 0.125-0.25 mg IV/IM
Severe: 0.5-2mg IV/IM, repeat q60min as required
Side effects: akathisia, extrapyramidal effects
Monitor QT interval (pre and post), Torsades de pointes, neuroleptic malignant syndrome, withdrawal dyskinesias
Delirium
Rehabilitation
- orientation stimuli
- adequate socialization
- eyeglasses/hearing aids
- mobilize
- adequate I&O
- educate and support
