Delerium: Unraveling a Transient Global Organic Mental Syndrome

Delerium (all higher function affected) A TRANSIENT GLOBAL ORGANIC MENTAL SYNDROME (recover or die (approx 50:50 in 2 years)) (not disease bec many causes) WITH DISORDERED COGNITION, ATTENTION AND, COMMONLY, (affects memory & rest of cognition) DISTURBED PSYCHOMOTOR BEHAVIOUR AND (wander around looking for familiar items/ppl) SLEEP-WAKE CYCLE, (awake at night, running around, sleep in day) DUE TO ABNORMAL CEREBRAL FUNCTION. (either chemical (alcohol), infection, metabolic or oxygenation prob) DSM IV Criteria for Delirium (sic) A. Disturbance of consciousness (ie. reduced clarity of awareness of environment with reduced ability to focus, sustain or shift attention). B. Change in cognition (eg. memory deficit, disorientation, language disturbance) or development of perceptual disturbance not better accounted for by dementia. C. Disturbance develops over short period of time (usually hours to days) and tends to fluctuate during course of day. (oft more active @ night) D. Evidence from history/physical exam./lab. findings of gen. med. condition, intoxication/withdrawal or multiple aetiologies. (evidence often not found) (But can be “Not otherwise specified”, due to “suspected” condition or other) NB: Confusion is a bad and confusing term and shouldn’t be used CLINICAL FEATURES • Reduced alertness, awareness, attention and concentration (though excessive sensitivity (often to sound – “everyone shouting”) sometimes seen); “dream like state” • Disorientation and memory impairment; • Fluctuation, variability and nocturnal worsening (classical); • Anxiety to terror; • Misinterpretations (not what you think it is), illusions, hallucinations (visual most common) and delusions (often paranoid);(being tortured in hospital) • Plucking restlessness (if bed/wheelchair bound), agitation or restless wandering; (looking for • • • • familiar items/people) Unco-operativeness, fearfulness, aggression; (due to paranoid delusions) Rambling if disruption of thinking severe; In world of their own, “tuned out”, “clouded”; Can have lucid intervals if given task to do Ill, perhaps sweating and tremulous. Collateral history is very important to compare to previous state NB: dementia usually takes 6 months – 1yr to onset OUTCOME (don’t need to know) 40% dead at 6 months 50% dead at 2 years INCIDENCE (don’t need to know) 16%-20% of elderly 1st admissions to psychiatric units About 15%-30% of hospitalised medical and surgical patients 50% of 70+ admitted to general medical wards show delirium at some point 35% of index admissions of uk 65+ years patients 22% of us prospectively studied cohort of 70+ years medical admissions COMMON CAUSES Heart Condition (MI, angina, HF) 24% UTI 17.5% Chest complaint (Pneumonia, COPD etc) 15% Carcinomatosis 5% Depression (not a cause but often a co-morbidity) 5% NB: Any serious illness/trauma state can cause it Correlation between the severity of illness and the severity of the delerium PREDISPOSING FACTORS Vision impairment Severe illness Cognitive Impairment (e.g. pre-existing dementia) Raised blood urea nitrogen/creatinine VULNERABILITY FACTORS Sensory deprivation/impairment e.g. Eyesight / Hearing problems Social isolation Increased sensation – e.g. pain Sleep deprivation Anxiety Depression PRECIPITATING FACTORS Use of physical restraints (not issue in UK) Malnutrition More than three medications added Use of bladder catheter Any iatrogenic event (harmful consequence of a procedure or intervention) MANAGEMENT • Seek and treat causes (cardiac, UTI etc – although often none found) • Symptomatic and supportive therapy Fluid and electrolytes Nutrition and vitamins Well-lit, calm, reassuring & orientating environment (family, articles from home) Good nursing care • Avoid drugs (for as long as possible) - haloperidol is safest – 0.5mg b.d. - NB: thioridazine no longer used - Benzodiazepines – used in alcohol withdrawl Definition of the syndrome. Its outcome. Its commoness. Some common causes. Clinical features. Management. Vulnerability/predisposing factors.