Dr Annette Downey Consultant Psychiatrist, Exeter & cognitive analytic therapist

1. DELIRIUM Dr Annette Downey Consultant Psychiatrist, Exeter & cognitive analytic therapist MRCPsych Course, Derriford June 2011

2. 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

3. 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

4. Features for Diagnosis of Delirium • Disturbance of consciousness, with reduced ability to focus, sustain or shift attention • 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 • The disturbance is over a short time (usually hours to days) & tends to fluctuate during the course of the day • 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.

5. 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.

6. 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

7. 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

8. 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?

9. 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.

10. Cytokines • Interleukin-2 therapy causes delirium & this is dose dependent • Mechanism? Christ in the Storm, Rembrandt

11. Other Types of Delirium • Delirium tremens • Benzodiazepine withdrawal

12. 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.’

13. 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 • 13 June 2011

14. 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.

15. Video demonstration of the CAM method

16. Delirium 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 • 16 June 2011

17. Differentiating: Delirium and 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 Annette Downey June 2011

18. 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 Causes of Delirium

19. Management begins with obtaining 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 Annette Downey June 2011

20. 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

21. 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 Supportive & behavioural management

22. 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.

23. Medical treatmentThere is not much research to support clinical practice 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 Annette Downey June 2011

24. 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 delirium Help with orientation – photos, assist at meal times, playing card games, talking about past times. Discussing the future

25. 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

26. Adopt A Person Centred Approach Annette Downey June 2011

27. 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. Annette Downey June 2011