Delirium Michele Ritter, M.D. Argy February, 2007
Delirium vs. Dementia • Dementia: • Slow evolution of multiple cognitive deficits • Delirium • DSM-IV: • Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention • A change in cognition (such as memory deficity, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for my a pre-existing 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 • Ther is evidence from the history, physical examination, or laboratory findings that the disturbance is cause by the direct physiological consequences of a general medical condition. • Includes Substance Intoxication Delirium, and Substance Withdrawal Delirium
Delirium – Case #1 • A 75-year old male with a history of coronary artery disease, hypertension and atrial fibrillation is brought to the ER by his wife because of lethargy and confusion. The patient’s wife states that the patient tripped on the cat four days earlier and fell, but “didn’t hurt himself”. Otherwise, he’s had no recent changes in medications, no recent fevers.
CNS abnormalities as cause of Delirium • Intracranial hemorrhage • Subdural hematoma • Epidural hematoma • Cerebral Vascular Accident • Ischemic or hemorrhagic stroke • Seizure • Post-ictal confusion • Brain tumors • Carcinomatous meningitis • Vasculitis
Delirium – Case # 2 A 20-year old Georgetown student is brought to Georgetown emergency room by his friend because he was found to be confused and lethargic. In the E.R. he is noted to have fever to 103°, nuchal rigidity on exam, and the following rash.
CNS Infections as cause of delirium • Meningitis • Bacteria: Neisseria meningitides, Strep. pneumoniae, Haemophilus influenzae, Listeria monocytogenes (in elderly). • Viruses: Enterovirus, Herpes simplex Virus (HSV), Cytomegalovirus • HIV: Crytpococcus • Encephalitis • HSV • Frequently “wacky” behavior for days to hours before hospitalization • Brain abscess • Infection with toxoplasmosis in HIV
Delirium Case # 3 A 34-year old male with no significant past-medical history presents to Georgetown ER after some lethargy and confusion right after finishing his first marathon. His friends state that he “never” drinks or uses drugs, and that he did a very good job of keeping hydrated with water and gatorade during the marathon.
Electrolyte abnormalities as cause of Delirium • Hyponatremia • Polydypsia (w/ free water) • SIADH • Hypernatremia • Diabetes insipidus • Hypercalcemia • Think of cancers: Squamous cell lung cancer, Multiple myeloma • Hypoglycemia • Uremia
Systemic Infections as cause of delirium • Urinary Tract Infections • Pneumonia • Intra-abdominal infections • Line infections • Sepsis • Hypoperfusion to the brain results in decreased mental status.
Delirium Case # 4 • An 88-year-old nursing home resident with a history of hypertension, Diabetes mellitus and an indwelling foley secondary to neurogenic bladder, presents to the ER with obtundation. She is noted on exam to have a low temperature at 34.7° C, a blood pressure of 88/40 and very cloudy urine in her foley.
Delirium Case # 5 • A 56-year-old male with a history of 2 packs of cigarettes/day for 40 years, and a history of a “clotting disorder” presents to the ER with one day of lethargy and confusion. On exam, the patient is afebrile, normotensive with a HR of 110, respiratory rate of 14 and Oxygen saturation of 92% on RA. In general he is oriented to self only, but does not appear to breathing heavily – in NAD. On lung exam there are decreased breath sounds bilaterally. His left lower extremity is noted to be more swollen than the right.
Respiratory abnormalities as cause of dementia • Hypoxia • Asthma • Pulmonary Embolism • Pulmonary Edema (Congestive Heart Failure) • Hypercapnia • COPD patients • Narcotic overdose
Delirium Case #6 • A 18-year old Georgetown college student is brought in to Georgetown ER by the GUTS emergency medical service. He was found staggering down Prospect St. at 3 am. On exam, patient is afebrile, normotensive, slightly tachycardic, and very beligerant. He has slurred speech, and is oriented to self only. Nausea and vomiting along with fecal incontinence ensues.
Drugs as cause for Delirium • Alcohol • D-Lysergic acid diethylamide (LSD) • Benzodiazepines • Narcotics • PCP
Delirium Case # 7 • An 88-year old female with a history of osteoporosis is brought to GUH by her granddaughter. The granddaughter states that the patient is usually “totally with it” and lives by herself. They spent the day yesterday picnicking in a field in Northern Virginia, and they had noticed some mosquitos bites afterwards, but that was it. Starting today, the patient was noticed to be acting very “wacky”. She also hadn’t gone to the bathroom all day the granddaughter states. • On exam the patient is afebrile, but tachycardic; Her mucus membranes are very dry, and she has mydrasis.
Delirium Case # 8 • A 42-year old female with a history of metastatic breast cancer is admitted to GUH with spinal cord compression. She is seen by neurosurgery, and decision is made to defer surgery but instead have patient undergo radiation therapy. Patient is noted over the next several days to have “wacky” behavior – at times oriented to self and place only.
Medications as cause for delirium • Anti-cholinergics • Benadryl • Tri-cyclic antidepressants • Muscle relaxants • Flexeril, skelaxin • Anti-emetics • Phenergan • Steroids • “steroid psychosis” • Anesthesia Medications
Final Case • A 79-year old female with a history of hypertension, peripheral vascular disease presents to the hospital with some mild confusion. The patient and her daughter states that since earlier that day, the patient has been forgetting things, and had a few episodes of not knowing where she was. She has had no recent changes in medications, no recent hospitalizations.
Final Case (cont.) • PMH: • Hypertension • Peripheral Vascular Disease – had a femoral-popliteal bypass in right leg 3 years ago • Allergies: NKDA • Outpatient Meds: • Lisinopril – 40 mg po QDay • Metoprolol – 25 mg po BID • Social History: • Lives with daughter; No history of tobacco or alcohol use; No other drug use; previously worked as history teacher (retired many years ago)
Final Case (cont.) • Review of systems: • Gen: No fever, no weakness, no weight loss/gain, no headache • CV: No chest pain, no palpitations • Resp: No cough, no SOB • GI: No abdominal pain, no nausea/vomiting, no diarrhea, no constipation • Heme: No easy bleeding, bruising
Final Case (cont.) • Physical Exam: • VS: 37.6° C, 112/60, 62, 16, 94% on RA • Gen.: Alert, but oriented only to self and place; at times seems to have trouble giving details of her medical history • CV: RRR, no murmurs auscultated • Resp.: LCTA bilaterally • Abd: soft, nontender, NABS • Ext.: No LE edema
Final Case (cont.) • Labs: • WBC: 9.8 Hgb.: 11.2 Hct. 33.8 Plt: 228 • Sodium: 132, Potassium: 4.0, Chloride: 100 CO2: 21, BUN 13, Cr. 0.8, Glucose 110 • Urinalysis: No protein, glucose, ketones; Leuk. Est: neg. , no WBCs, no RBCs
CNS Process CNS Infections Infections/Sepsis Electrolye Disturbances Hyponatremia Hypoglycemia Hypercalcemia Medications Alcohol/Drugs Hypoxia/Hypercapnia Myocardial Infarction Delirium Cases -- Synopsis