Delirium Cases in Young and Elderly Patients: Clinical Insights

1. Delirium Pat Oakley Delirium

2. Case 1 • 17 year old girl with previous label “borderline personality disorder” presents to ED 2200 • Argument with parents about boyfriend that evening, went to the mall and then locked herself in her room • Parents called ambulance 2 hours later when she was screaming and abusive, intermittently drowsy. • Empty packets of tablets: paracetamol, phenergan.

3. In ED • Carefully assessed re paracetamol toxicity- levels OK • Notes record:“Very difficult, abusive, screaming, intermittently drowsy, Malingering?” • Activated charcoal • Admission for tox review in am

4. In AM • Unhappy, dishevelled young lady • OGT in nose • IDC has been inserted • 37.1 C, HR 90, 110/70. lucid, but wary. • ECG N • Pupils not dilated, no tremor, armpits dry, not flushed. • ECG N • Discharged after psychiatric input.

5. Case 2 • F1 call. • 90 year old man from home, # NOF ORIF 24 hours ago. Usually independent • Hallucinating, yelling at NS, grasping bedrails and climbing out. • Bladder scan 900mL.

6. Medications • Pravastatin 40mg • Candesartan 12mg • Aspirin 100mg • Endep 25mg nocte • Endone 20mg bd • Clexane 20mg

7. Examination • Delirium, no obvious focal neuro deficit • Pupils small • HR 100, BP 150/90, no fever • No obvious septic focus

8. Additional history from family • Usually lucid, but did this last GA • Recently a bit forgetful; locked self out of home 3 times in last month • Home brewer, intake of alcohol…

9. Rx • Sedated; diazepam 2.5 mg increments at 10 minute intervals until asleep • IDC • Workup- CXR (N), msu (N), FBC and EUC (essentially N, Hb 90). • Ceased endep • Reviewed that evening, still agitated, though less so • Accepted quetiapine 25mg o

10. Progress • Remained confused, but less aggro, settling over 5 days. Quetiapine stopped day 6, IDC out,

11. Definition • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. • A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect

12. Definition • The brain gets sick and stops working because the body is sick…occasionally due to solely CNS pathology/poisoning

13. Delirium.. • Risk • Precipitants • Assessment • management

14. Risk Factors • Baseline cognitive function • Sensory deprivation …..Age

15. Precipitant • Drugs • Ingestion • Therapeutic intoxication • Withdrawal • As cofactors • Illness • Environment • Sleep • Noise • dehyration

16. Ingestions • Anything designed to get into brains.. • Anticholinergics • SSRI (plus serotonergics..SS) • Opiates- metabolites • Anticonvulsants • LiCO3 • Others..lipophyllic beta blockers, cyclosporin, • Or anything that makes you critically ill…

17. Withdrawal • Alcohol • Benzodiazepines • Opiates- esp longer acting • Some anticonvulsants- esp barbiturates • Dopamine agonists • Centrally acting antihypertensives,

18. Illness- look systemically first • Any severe infection • Hepatic failure-encephalopathy (look for the signs) • Renal failure (look at drug accumulation) • CNS infections • Hypoxia, electrolyte disturbance (low Na), urine retention, anything painful

19. CNS • Intracranial pathology- SDH, SAH… • Rarely CVA unless complicated by seizure, previous others cva, or mistaken manifestation eg dysphasia

20. Assessment • Medical history- Risk • Drug chart • Assess- what medical precipitants are likely here? • Ix- look for those precipitants likely to be present…. • Drug levels and CAT head rarely useful

21. Management • The Cause…there will be multiple • Cessation of relevant meds • Adequate hydration, environment, analgesia • Management of alcohol/benzo withdrawal • ?Special…if needed for pt safety

22. Management..control • Role of antipsychotics…limited evidence • Nil evidence of any real benefit…but difficult • Old “typical” agents recommended, EPS, less sedating • Atypicals- less EPS, more sedating, longer T1/2, not actually authorised. Quetiapine currently the fashion • Role of benzodiazepines • Match duration of action to requirements (midazolam doesn’t last) • Titrate to effect…ivi diazepam in small aliquots is still a pretty good idea

23. Restraints? Best avoided

24. The Sexy Syndromes

25. Serotonin Syndrome • Too much serotoinin-Intrasynaptically • Usually a synergistic combination of 2 serotonergic drugs; or overdose of SSRI • Neuromuscular excitation • Clonus • Hyperreflexia • rigidity • CVS • Tachycardia, hypertension • Autonomic • Sweating, diarrhoea, vomiting, Fever • Delirium

26. Neuroleptic Malignant Syndrome • Dopamine blocking drugs; abrupt cessation of dopaminergics, often a precipitating illness • Autonomic • Drooling, sweating, sialorrhea • Ileus or diarrhoea, urinary retention • Hypo/hypertension • Tachy/bradycardia • EPS • Lead pipe rigidity, cogwheeling • bradykinesia • Fever • >37.5 • Delirium • hypoactive

27. Anticholinergic Delirium • Overdose of Muscarinic ACh blockade; or introduction in a susceptible patient; or new illness in a susceptible patient on anticholinergics • Autonomic • Pupils • Dry armpits • Tachycardia • Urine retention • ileus • Delirium • Hallucinations prominent