KNB delirium ppt

1. Delirium
Abbas Johar

2. Definition
• Transient, usually reversible, mental
dysfunction and manifests clinically with a
wide range of neuropsychiatric abnormalities

3. Pathophysiology
• Fundamental mechanism(s) remain(s) unclear
• The characteristic EEG findings demonstrate
global functional derangements
• focal dysfunction localized to nondominant
cortex.
• NTs  ↓Ach, ↑D, ↑/↓ HT
• Inflammation  microglial  neurotoxicity

4. Epidemiology
• the most common behavioral disorder in a medical-
surgical setting
• The prevalence in:
• General hospital patients is 10–30%.
• 50% of surgical patients in the postoperative period.
• in 25–40% of cancer pt. and in up to 85% of with
advanced cancer.
• Close to 80% of terminal patients before they die
• potentially poor prognosis; hospital mortality rates is
22% to 76%, as high as mortality rates associated MI
and sepsis !

5. Etiology
• Multifactorial
• interrelationship between patient
vulnerability (ie, predisposing factors) and the
occurrence of noxious insults (ie, precipitating
factors).

7. • Dementia  half of delirious pt. have
background Hx of dementia + 2-5X risk of
developing delirium.
• Nearly any chronic medical condition can
predispose to delirium

9. • Decreased mobility is strongly associated with
delirium and concomitant functional decline
Eg. Restraints, indwelling bladder catheter.
• Iatrogenic events increase 3-5X in >65 yrs
(eg. Procedures, bleeding, allergic reactions)
• Organ dysfunction (Renal/Hepatic).
• Occult diseases (Resp. F, CHF, infection).

12. Presentation
Other features:
- disorientation (TP>P),
- cognitive impairments
- psychomotor agitation or
retardation,
- perceptual disturbances
- paranoid delusions
- emotional lability,
- sleep-wake cycle disruption
Cardinal features:
- Acute onset (hours, days)
Inattention
- fluctuating course (lucid
intervals).
- Poor concentration
- Incoherent speech

13. Classification of Delirium
Hypoactive:
- Lethargy
- Depressed psychomotor activity
- Common in older pt.
-Often under-recognized
- Poorer prognosis
Hyperactive: 15%
Agitation
increased vigilance,
concomitant hallucinations
BOTH 50%

14. Evaluation
• most widely used is the CAM (Confusion
assessment method)
• The algorithm has a sensitivity of 94-100%,
specificity of 90-95%

16. 3D-CAM Algorithm

17. DDx (ALTERED MENTAL STATUS)
CHARACTERISTIC DELIRIUM DEMENTIA DEPRESSION ACUTE PSYCHOSIS
Onset Acute (hours to days) Progressive, insidious
(weeks to months)
Either acute or
insidious
Acute
Course over time Waxing and waning Unrelenting Variable Episodic
Attention Impaired, a hallmark
of delirium
Usually intact, until
end-stage disease
Decreased
concentration and
attention to detail
Variable
Level of
consciousness
Altered, from
lethargic to
hyperalert
Normal, until end-
stage disease
Normal Normal
Memory Impaired commonly Prominent short-
and/or long-term
memory impairment
Normal, some short-
term forgetfulness
Usually normal
Orientation Disoriented Normal, until end-
stage disease
Usually normal Usually normal
Speech Disorganized,
incoherent, illogical
Notable for
parsimony, aphasia,
anomia
Normal, but often
slowing of speech
(psychomotor
retardation)
Variable, often
disorganized
Delusions Common Common Uncommon Common, often
complex
Hallucinations Usually visual Sometimes Rare Usually auditory and
more complex
Organic etiology Yes Yes No No

21. Prevention
RISK FACTOR INTERVENTION PROTOCOL
Cognitive
impairment
•Orienting communication, including orientation board
•Therapeutic activities program
Immobilization •Early mobilization (eg, ambulation or bedside exercises)
•Minimizing immobilizing equipment (eg, restraints, bladder catheters)
Psychoactive
medications
•Restricted use of PRN sleep and psychoactive medications (eg, sedative-
hypnotics, narcotics, anticholinergic drugs)
•Nonpharmacologic protocols for management of sleep and anxiety
Sleep deprivation •Noise-reduction strategies
•Scheduling of nighttime medications, procedures, and nursing activities to
allow uninterrupted period of sleep
Vision impairment •Provision of vision aids (eg, magnifiers, special lighting)
•Provision of adaptive equipment (eg, illuminated phone dials, large-print
books)
Hearing impairment•Provision of amplifying devices; repair hearing aids
•Instruct staff in communication methods
Dehydration •Early recognition and volume repletion

22. THANKS

23. References
• 1- Bradley’s neurology in clinical practice, 5th
edition, Delirium, Ch. 4, p. 27-37.
• 2- Hazzard's Geriatric Medicine and
Gerontology, 7e, Ch. 47, Delirium
• 3- CAM Form
http://www.viha.ca/NR/rdonlyres/6121360B-
B90F-4EF3-88F6-
D50CC4825EE7/0/camshortform.pdf