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Delirium

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In medicine, delirium is a "disorder characterized by confusion; inattentiveness; disorientation; illusions; hallucinations; agitation; and in some instances autonomic nervous system overactivity )."[1][2]

According to the Diagnostic and Statistical Manual of Mental Disorders, delirium is "reduced ability to think or concentrate, restlessness, anxiety, irritability, drowsiness, hypersensitivity to stimuli, nightmares."[3]

Etiology / cause

Dysglycemia may contribute to delirium.[4]

Diagnosis

This topic has been reviewed.[5][6]

Among hospitalized geriatric patients, "failure to identify either year or month correctly was 95% sensitive and 86.5% specific for the detection of cognitive impairment".[7]

Specific disorders such as substance withdrawal syndrome, intoxication, Wernicke encephalopathy, and osmotic demyelination syndrome (central pontine myelinolysis) should be excluded.

Confusion Assessment Method (CAM)

The confusion assessment method (CAM), which is an algorithm with four criteria based on the Diagnostic and Statistical Manual of Mental Disorders can help diagnose when the first two criteria are present and either the third or fourth criteria is present:[8][5]

  1. acute onset and fluctuating course
  2. inattention
  3. disorganized thinking
  4. altered level of consciousness

In the CAM-S, items 2-3 are rated as 0 (absent), 1 (mild), or 2 (marked). For the first item, acute onset and fluctuation was rated 0 (absent) or 1 (present).[9] In this study, no cut off score reliably diagnosed delirium, but a score of less than 2 was rarely associated with delirium that was independently diagnosed.

Mini-mental state examination (MMSE)

The Mini-mental state examination (MMSE) can also help and can be found in the appendix of its original publication.[10]

Components of the MMSE have been studied:

caption
Component Sensitivity Specificity
Three item recall[11] 54% 96%
Disorientation to year[7] 86% 94%
Counting backwards cell cell

Six item screener (SIS)

The examiner first asks the patient to remember three items: GRASS PAPER SHOE. The examiner can repeat the words 3 times as needed to help the patient.[12]

Orientation to time

  • Year
  • Month
  • Day of the week

Recall of three items (one point each)

  • Sensitivity 74%
  • Specificity 77%

Subsyndromal delirium

Subsyndromal delirium may cause morbidity among hospitalized individuals.[3]

Treatment

For patients who have agitation, randomized controlled trials have found that:

Antipsychotic agents, such as haloperidol less than 3.0 mg per day, can improve delirium according to a systematic review by the Cochrane Collaboration.[15] Haloperiderol may be best.[16]

Cholinesterase inhibitors like donepezil do not clearly help, but they have not been well studied.[17]

Benzodiazepines may worsen delirium[18] and no evidence supports their use.[19]

Prevention

Clinical practice guidelines by National Institute for Health and Clinical Excellence direct prevention.[20]

Who is at risk?

The strongest risk factors for developing delirium are impaired cognition and psychotropic drug use.[21]

Clinical prediction rule have been developed to help the prediction.

Inouye et al studied hospitalized geriatric patients and assigned one point to each of the following:[22]

  • vision impairment
  • severe illness as defined by APACHE II score of 17 or more
  • cognitive impairment. Score of 23 or less on the Mini-Mental State Examination (MMSE). The MMSE can be found in the appendix of its original publication.[10]
  • high blood urea nitrogen/creatinine ratio of 18 or more

The rates of delirium were:[22]

  • 0 points 3%
  • 1-2 points 16%
  • 3-4 points 32%

These results have been independently validated with respective incidences of delirium of 4%, 12%, and 38%.[23]

Rudolph et al studied geriatric patients undergoing cardiac surgery and used four following predictors: abnormal Mini Mental State Examination, abnormal Geriatric Depression Scale prior cerebrovascular disease, and abnormal serum albumin.[24] This rule has not been independently validated.

Interventions

"Proactive geriatric consultation may reduce delirium incidence and severity...prophylactic low dose haloperidol may reduce severity and duration of delirium episodes according to a systematic review by the Cochrane Collaboration."[25]

In hip surgery (about 25% were for hip fracture), geriatric patients with at least one point on the Inouye prediction rule (see above), haloperidol 1.5 mg per day was started on admission and continued until 3 days after surgery reduced the severity and duration of delirium.[23] The incidence of delirium was insignificantly reduced from 15.1% and 16.5% to 15.1%. However, for secondary outcomes, the duration of delirium was reduced by 6 days and the duration of hospitalization was significantly reduced by 5 days. There were no drug-related side effects. Patients in both the treatment and control groups received geriatric consultation.

Also in surgery of hip fracture, the use of light sedation with propofol may reduce postoperative delirium in geriatric patients as compared with deep sedation.[26]

Prognosis

Many geriatrics patients have delirium persist at hospital discharge and for months afterwards.[27]

References

  1. Anonymous (2016), Delirium (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Breitbart, William; Yesne Alici (2008-12-24). "Agitation and Delirium at the End of Life: "We Couldn't Manage Him"". JAMA 300 (24): 2898-2910. DOI:10.1001/jama.2008.885. Retrieved on 2009-01-07. Research Blogging.
  3. 3.0 3.1 Cole M, McCusker J, Dendukuri N, Han L (June 2003). "The prognostic significance of subsyndromal delirium in elderly medical inpatients". J Am Geriatr Soc 51 (6): 754–60. PMID 12757560[e]
  4. Duning T, van den Heuvel I, Dickmann A, Volkert T, Wempe C, Reinholz J et al. (2010). "Hypoglycemia aggravates critical illness-induced neurocognitive dysfunction.". Diabetes Care 33 (3): 639-44. DOI:10.2337/dc09-1740. PMID 20032274. PMC PMC2827523. Research Blogging.
  5. 5.0 5.1 Wong CL, Holroyd-Leduc J, Simel DL, Straus SE (2010). "Does this patient have delirium?: value of bedside instruments.". JAMA 304 (7): 779-86. DOI:10.1001/jama.2010.1182. PMID 20716741. Research Blogging. Review in: Ann Intern Med. 2011 Feb 15;154(4):JC2-12 Review in: Evid Based Ment Health. 2011 Feb;14(1):4
  6. Mitchell AJ, Malladi S (2010). "Screening and case-finding tools for the detection of dementia. Part II: evidence-based meta-analysis of single-domain tests.". Am J Geriatr Psychiatry 18 (9): 783-800. DOI:10.1097/JGP.0b013e3181cdecd6. PMID 20808094. Research Blogging.
  7. 7.0 7.1 O'Keeffe E, Mukhtar O, O'Keeffe ST (2011). "Orientation to time as a guide to the presence and severity of cognitive impairment in older hospital patients.". J Neurol Neurosurg Psychiatry 82 (5): 500-4. DOI:10.1136/jnnp.2010.214817. PMID 20852313. Research Blogging.
  8. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (December 1990). "Clarifying confusion: the confusion assessment method. A new method for detection of delirium". Ann. Intern. Med. 113 (12): 941–8. PMID 2240918[e]
  9. Inouye SK, Kosar CM, Tommet D, Schmitt EM, Puelle MR, Saczynski JS et al. (2014). "The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts.". Ann Intern Med 160 (8): 526-33. DOI:10.7326/M13-1927. PMID 24733193. Research Blogging.
  10. 10.0 10.1 Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of psychiatric research 12 (3): 189-98. DOI:10.1016/0022-3956(75)90026-6. PMID 1202204. Research Blogging.
  11. Borson S, Scanlan JM, Chen P, Ganguli M (2003). "The Mini-Cog as a screen for dementia: validation in a population-based sample.". J Am Geriatr Soc 51 (10): 1451-4. PMID 14511167[e] Review in: Evid Based Ment Health. 2004 May;7(2):38
  12. Carpenter CR, Despain B, Keeling TN, Shah M, Rothenberger M (2011). "The Six-Item Screener and AD8 for the Detection of Cognitive Impairment in Geriatric Emergency Department Patients.". Ann Emerg Med 57 (6): 653-61. DOI:10.1016/j.annemergmed.2010.06.560. PMID 20855129. Research Blogging.
  13. Agar MR, Lawlor PG, Quinn S, Draper B, Caplan GA, Rowett D et al. (2016). "Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial.". JAMA Intern Med. DOI:10.1001/jamainternmed.2016.7491. PMID 27918778. Research Blogging.
  14. Taylor DM, Yap CY, Knott JC, Taylor SE, Phillips GA, Karro J et al. (2016). "Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial.". Ann Emerg Med. DOI:10.1016/j.annemergmed.2016.07.033. PMID 27745766. Research Blogging.
  15. Lonergan E, Britton AM, Luxenberg J, Wyller T (2007). "Antipsychotics for delirium". Cochrane Database Syst Rev (2): CD005594. DOI:10.1002/14651858.CD005594.pub2. PMID 17443602. Research Blogging.
  16. Campbell N, Boustani MA, Ayub A, Fox GC, Munger SL, Ott C et al. (2009). "Pharmacological management of delirium in hospitalized adults--a systematic evidence review.". J Gen Intern Med 24 (7): 848-53. DOI:10.1007/s11606-009-0996-7. PMID 19424763. PMC PMC2695535. Research Blogging.
  17. Overshott R, Karim S, Burns A (2008). "Cholinesterase inhibitors for delirium". Cochrane Database Syst Rev (1): CD005317. DOI:10.1002/14651858.CD005317.pub2. PMID 18254077. Research Blogging.
  18. Breitbart W, Marotta R, Platt MM, et al (February 1996). "A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients". Am J Psychiatry 153 (2): 231–7. PMID 8561204[e]
  19. Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB (2009). "Benzodiazepines for delirium". Cochrane Database Syst Rev (1): CD006379. DOI:10.1002/14651858.CD006379.pub2. PMID 19160280. Research Blogging.
  20. O'Mahony R, Murthy L, Akunne A, Young J, for the Guideline Development Group (2011). "Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of Delirium.". Ann Intern Med 154 (11): 746-751. DOI:10.1059/0003-4819-154-11-201106070-00006. PMID 21646557. Research Blogging.
  21. Dasgupta M, Dumbrell AC (October 2006). "Preoperative risk assessment for delirium after noncardiac surgery: a systematic review". J Am Geriatr Soc 54 (10): 1578–89. DOI:10.1111/j.1532-5415.2006.00893.x. PMID 17038078. Research Blogging.
  22. 22.0 22.1 Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME (September 1993). "A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics". Ann. Intern. Med. 119 (6): 474–81. PMID 8357112[e]
  23. 23.0 23.1 Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al (October 2005). "Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study". J Am Geriatr Soc 53 (10): 1658–66. DOI:10.1111/j.1532-5415.2005.53503.x. PMID 16181163. Research Blogging.
  24. Rudolph JL, Jones RN, Levkoff SE, et al (January 2009). "Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery". Circulation 119 (2): 229–36. DOI:10.1161/CIRCULATIONAHA.108.795260. PMID 19118253. Research Blogging.
  25. Siddiqi N, Stockdale R, Britton AM, Holmes J (2007). "Interventions for preventing delirium in hospitalised patients". Cochrane Database Syst Rev (2): CD005563. DOI:10.1002/14651858.CD005563.pub2. PMID 17443600. Research Blogging.
  26. Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB et al. (2010). "Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair.". Mayo Clin Proc 85 (1): 18-26. DOI:10.4065/mcp.2009.0469. PMID 20042557. PMC PMC2800291. Research Blogging.
  27. Cole MG, Ciampi A, Belzile E, Zhong L (January 2009). "Persistent delirium in older hospital patients: a systematic review of frequency and prognosis". Age Ageing 38 (1): 19–26. DOI:10.1093/ageing/afn253. PMID 19017678. Research Blogging.