​Kembara Xtra - Medicine - Delirium

​Kembara Xtra - Medicine - Delirium 
Introduction 
A transitory neurocognitive consequence of sickness and/or medication(s) expressed by new confusion and decreased attention Requires examination in order to prevent morbidity and mortality expressed by new confusion and impaired attention 

Epidemiology ( Incidence and Prevalence) 
● Predominant age: elderly adults 
● Predominant sex: male = female Incidence of >50% in older patients in intensive care units; 11–51% in postoperative patients; 19% after intracranial surgery and 42% after neurovascular surgery; 10–40% in hospitalized older patients; 20–22% in nursing home/post–acute–care patients. Prevalence of less than one to two percent in outpatients, eighteen to thirty-five percent or more in older patients seen in emergency departments, fourteen percent or more in older patients treated in post-acute care settings.


Etiology and Pathophysiology
Multifactorial: considered to occur from a reduction in physiologic reserves with aging, resulting in a vulnerability to additional stressors Often results from an interaction between risk factors that either predispose or precipitate the condition

Risk Factors 
Risk factors that predispose to the condition – Advanced age, greater than 70 years; – A history of cognitive impairment; – A limitation in functional ability
– Dehydration
– A previous history of alcohol consumption – Malnutrition – Impairment in hearing or vision – Multiple co-occurring disorders
 Contributing, or Predisposing, Risk Factors - A serious condition affecting any organ system(s)
– Polypharmacy (five or more drugs) – Medical devices (such as urine catheters and shackles)
– Particular pharmaceuticals, most notably benzodiazepines, opioids, anticholinergics like diphenhydramine, and high-dose neuroleptics – Iatrogenic events of any kind – Pain – Surgical procedures – Lack of sleep

Associated Conditions 

There are several, however the following are the most prevalent ones:
 A new medicine, or a tweak to an existing medicine  Infections (meningitis should be considered in addition to pneumonia, bronchitis, and urinary tract infections)  Toxic metabolic (particularly renal failure and hepatic failure, low sodium levels, and increased calcium levels) ● Heart attack or stroke ● Alcohol or drug withdrawal A history of cognitive impairment raises the likelihood of adverse outcomes.

The diagnosis of delirium is made after careful consideration of the patient's medical history, careful observation of their behavior, and careful evaluation of their cognitive abilities.
– According to the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), diagnostic criteria include the following:  Alteration in cognition that is not the result of dementia or coma Disturbance in attention and awareness
Evidence from history, exam, or lab that the disturbance is caused by the physiologic consequence of a medical condition, intoxicating substance, medication use, or more than one cause. The presence of an additional disturbance in cognition (such as a deficit in memory, language, visuospatial ability, disorientation, or perception). The onset of the disturbance occurring over a short period of time (hours to days). The disturbance fluctuating throughout the course of the day.
– The Confusion Assessment Method (CAM) is the clinical instrument that has been the most thoroughly validated and evaluated (sensitivity 94– 100% and specificity 90–95% (3)[B]). It has been modified for use in the intensive care unit (ICU) in both adults and children (pediatric CAM-ICU [pCAM-ICU]).

Caution 
The CAM is characterized by the following four essential diagnostic features: – Acute change in mental status – Fluctuating course
- Inattention
- Cognitive disarray or an altered state of consciousness A number of symptoms that are not diagnostic may be present, including the following: – Difficulties with both short-term and long-term memory
– Sleep–problems with the sleep-wake cycle
- Experiences of hallucinations and/or delusions
- Emotional lability
- Shakings as well as asterixis
 Subtypes are categorized according to the patient's state of consciousness. One-fifth of patients have hyperactive delirium, which is characterized by noisy, agitated, restless, and disruptive behavior.
- Hypoactive delirium, which accounts for 20% of cases, is characterized by calm confusion; sleepiness; sitting without eating, drinking, or moving; and mixed delirium, which accounts for 50% of cases and includes characteristics of both hyperactive and hypoactive delirium. – Subsyndromal delirium (23%): some delirium symptoms but does not proceed to full delirium – Normal consciousness delirium (15%): still displays disordered thinking, coupled with acute onset, inattention, and fluctuating mental status – Subsyndromal delirium (23%): still displays disorganized thinking, along with acute onset, inattention, and fluctuating mental status – Subsyndromal deli
HISTORY
The progression of changes in mental status throughout time Recent changes in medication Symptoms of infection New neurologic indicators Sudden shifts in functional ability

Clinical Examination 
An exhaustive test of the cardiovascular and respiratory systems is required.
Generally speaking, focal neurologic symptoms are not present.
Shorter cognitive screens have been studied in delirious patients (i.e., the Short Blessed Test [SBT], the Brief Alzheimer Screen [BAS], and the Ottawa 3DY), and they may be helpful if performed serially over time. The Mini-Mental State Examination (MMSE) is the most well-known and studied cognitive screen, but it may not be the most appropriate in an acute care setting.
 Evaluation of the gastrointestinal tract and the urinary tract for the presence of urine retention and constipation

Differential Diagnosis 

 Depression, which is characterized by a disturbance in mood and a normal level of consciousness and can last anywhere from weeks to months.  Acute stress disorder (disruption of mood, usual state of consciousness, brought on by a stressful incident)  Manic episode of bipolar disorder (characterized by rapid speech and impulsivity; duration varies from weeks to months; elderly persons are more likely to experience gradual onset).  Dementia (with a gradual start, issues with memory, a normal level of consciousness, and shifts in severity over the course of days to weeks)
 Psychosis (the onset of which in elderly persons is usually gradual) ● Seizure disorders (i.e., nonconvulsive status epilepticus)

Laboratory Findings 

Initial Tests (lab, imaging)
 Labs: guided by history and physical exam; comprehensive metabolic panel (CMP), complete blood count (CBC), urinalysis (UA), urine culture, and blood culture - Medication levels (digoxin, theophylline, and antiepileptics) in cases when they are relevant if it's medically essential, a chest radiograph and an electrocardiogram Additional Examinations, as well as Other Important Factors
 If preliminary lab tests do not suggest a precipitator of delirium, the following should be taken into consideration: — Gases found in arterial blood
– Troponin – A screening for toxicology
— Ammonia –
- The thyroid stimulating hormone, sometimes known as TSH. - Thiamine
 A noncontrast-enhanced head CT scan should be performed if the patient has recently fallen, is currently taking anticoagulants, or has recently developed new focal neurologic symptoms.
- Exclusion of the possibility of a mass prior to lumbar puncture
Other diagnostic procedures include a lumbar puncture, which is only performed in very rare cases.  Electroencephalogram (only performed when absolutely essential)

Prevention 
The most effective method of treatment is prevention: – There is much data supporting multicomponent therapies that do not involve the use of pharmaceuticals. The Hospital Elder Life Program, sometimes known as HELP, is a strategy that is utilized frequently:  Address any immediate medical concerns, such as treating any underlying conditions, maintaining vital signs, and staying hydrated.
Utilize orientation boards, clocks, and calendars as part of your reorientation efforts.
Offer assistance in the form of eyeglasses, hearing aids, and interpreters, and encourage family participation.
Ensure that you are adequately hydrated and fed.
 The need for early mobilization
○ Avoid constraints.
Activate the practice of self-care.
Attempt to normalize your sleep–wake cycle by discouraging naps, keeping the curtains open during the day, and giving priority to sleep that is uninterrupted.
Controlling discomfort without the use of opioids
 Modifications to medicine (elimination or reduction of psychoactive substances and anticholinergic medications, placement of emphasis on nonpharmacologic treatments)  The use of pharmaceutical treatments for the management of symptoms (reserved for extreme cases) Hospitalized patients who are at risk for developing delirium can have their risk reduced by 33 percent if they receive treatment for one or more of six risk factors, including cognitive impairment, sleep deprivation, dehydration, immobility, vision impairment, or hearing impairment.

General Measures 

 Training for the personnel on how to de-escalate potentially dangerous situations. Investigating potential underlying causes, such as hypotension, hypoxia, hypoglycemia, drug overdose or withdrawal, and others.
Take out any tubes or catheters that aren't necessary.
Encourage participation from all members of the family.
● Patients who have just had surgery need to be observed for - Infarction of the heart muscle/ischemia
– Infection (for example, pneumonia or an infection of the urinary tract) – Pulmonary embolism
- Retention of urine or stool (try to remove catheter before the postoperative day 2 deadline) - Anemia/bleeding
The type of anesthesia administered (general versus epidural, for example) may have an effect on the likelihood of delirium. It is possible that the depth of anesthesia has an effect on the risk of delirium. Sedation in the ICU and avoiding benzodiazepines both have the potential to lower risk.
● Multifactorial treatment: Identify the variables that contributed to the condition and provide preventative care in order to minimize iatrogenic complications. Pay particular attention to – CNS oxygen delivery (try to attain):
 SaO2 greater than 90%, with the aim of SaO2 greater than 95%
○ Systolic BP <2/3 of baseline or >90 mm Hg
○ Hematocrit >30% – Fluid/electrolyte balance
 Sodium, potassium, and glucose levels are normal; glucose levels in diabetics should be less than 300 mg/dL. Fluid overload or dehydration should be treated.
- Provide treatment for pain Take acetaminophen as prescribed, along with morphine as needed (PRN), for instance.


Caution 

Delirium is a risk whenever a patient's medication is altered in any way.
● Avoid meperidine (Demerol).
● Eliminate unneeded drugs.
- Determine whether any newly experienced symptoms might be the result of an adverse reaction to one of Beers' drugs.
Constipation and urine retention can cause delirium, so it is important to monitor and control the function of both the intestine and the bladder.
Check for urine retention and ensure you have a bowel movement at least once per 48 hours.
● Prevent serious hospital-acquired disorders.
Invest in a mattress that can relieve pressure.
Stay away from urinary catheters at all costs.
Spirometry with an incentive should be encouraged.
Prophylaxis for venous thromboembolism (VTE) if the patient is bedridden
- Rapid deployment of resources
- Environmental stimulation
 Clock and calendar Soft lighting with drapes open during the day Music and television, if desired Sleeping glasses and hearing aids Sleeping
• A calm and dark atmosphere • Gentle music • A massage for relaxation and therapy
 The use of restraints is associated with an increased risk of delirium as well as falls and injuries. Patients who are at risk of hurting themselves or their caretakers should only receive this treatment as a last resort. Eliminate at the earliest opportunity.


Medications 
Although nonpharmacologic techniques are favored for early therapy, medication may be required for severe agitation and behaviors that cause injury, particularly in the context of an intensive care unit (ICU).
● No FDA-approved medicine for delirium There is no evidence to support the use of medication as a preventative measure. First Line
 For the temporary relief of symptoms such as unbearable agitation or hallucinations: - Antipsychotic Medication (in the Order of the Alphabet)
○ Aripiprazole (Abilify) 2 to 5 mg PO daily to BID
 Haloperidol (Haldol): initially, 0.25 to 0.50 mg PO/IM; reevaluate and possible redose hourly until symptoms are controlled, and then utilize an effective dose of up to once every other day on an as-needed basis. The use of antipsychotics for the purpose of preventing delirium in intensive care units is not supported by the guidelines for critical care.
○ Olanzapine (Zyprexa) 2.5 to 5.0 mg PO daily to BID
○ Quetiapine (Seroquel) 12.5 to 25.0 mg PO BID–TID
Risperidone (Risperdal): 0.25 to 0.50 mg orally once day Contraindications: Patients with parkinsonism or Parkinson disease should not take haloperidol.
Antipsychotics have the potential to create extrapyramidal effects and to raise the risk of falling. Antipsychotics also have the potential to lengthen the QT interval. Aripiprazole, also known as Abilify, has a QT prolonging effect that is either mild or nonexistent.
The alpha-2 agonist dexmedetomidine is the pharmaceutical of choice for the management of sedation in intensive care unit (ICU) patients. It is the only drug that has been demonstrated to possibly lessen the length of delirium, hence it is the recommended choice. Hypotension and bradycardia are the chief unintended consequences that can be caused by using this medicine. Clonidine has also been shown to be useful in some studies as an oral bridge off of dexmedetomidine. Melatonin and melatonin agonists are receiving interest as sleep aids in intensive care unit patients.


Second-Line Treatment: Benzodiazepines should be avoided in most cases, with the exception of alcohol withdrawal, patients who take them routinely at baseline, and situations in which antipsychotics are unsafe to use.
Benzodiazepines can cause delirium. Initially, 0.25 to 0.50 mg PO/IM/IV TID–QID PRN; may need to adapt to effect; cholinesterase inhibitors should be avoided. Lorazepam (Ativan): the recommended dosage range is 0.25 to 0.50 mg.