|
 
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| PG CORNER |
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| Year : 2019 | Volume
: 3
| Issue : 2 | Page : 184-187 |
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Handling delirium on call
Sachin Mahajan
Department of Psychiatry, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| Date of Submission | 27-Aug-2019 |
| Date of Decision | 21-Oct-2019 |
| Date of Acceptance | 22-Oct-2019 |
| Date of Web Publication | 18-Dec-2019 |
Correspondence Address:
Dr. Sachin Mahajan
Old RMO Hostel Room No. 318, Seth GSMC and KEM Hospital, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | 4 |
DOI: 10.4103/aip.aip_53_19
Delirium is a common cause of disturbed behavior in medically ill people and is often undetected and poorly managed. It is a condition at the interface of medicine and psychiatry that is all too often owned by neither. Despite its clinical importance, delirium is often not detected, or is misdiagnosed as or other psychiatric illness.Hence, identification of risk factors, education of professional carers, and a systematic approach to management can improve the outcome of the syndrome. This article is for psychiatry postgraduate students to understand various aspects of delirium, bedside assessment with management of the patient with a focus on etiology , predisposing factors ,pathogenesis & different types of presentation in clinical practice.
Keywords: Delirium, Psychiatric emergency, Confusional state
How to cite this article:
Mahajan S. Handling delirium on call. Ann Indian Psychiatry 2019;3:184-7 |
A psychiatry resident on emergency duty receives many calls for crisis intervention, substance withdrawal, patient in altered sensorium, and behavioral complaints. Most of these calls are for patients admitted in medicine, surgery, orthopedic, and intensive care unit (ICU) settings. Therefore, it is necessary for every psychiatry postgraduate student not only to have adequate knowledge about confusional states to asses such patients in emergency settings but also to manage these patients who may be restrained or on ventilation for life support. Such patients are a challenge to residents from other disciplines as they are unable to manage aggression and behavioral problems.
Every emergency has a call for handling delirium. This article is for psychiatry postgraduate students to understand various aspects of delirium, bedside assessment with management of the patient.
An acute confusional state is characterized by sudden decline in both consciousness and cognition, with particular impairment in attention. Delirium is a complex neuropsychiatric syndrome presenting primarily with disturbances of cognition, perception and sensorium, alertness, sleep/wake cycle, and psychomotor behavior in the context of a medical etiology. This variability may overlap with other psychiatric syndromes and has led to substantial under recognition and under treatment in clinical settings.[1] Though reversible, it can be life-threatening if not treated adequately. Hence, one should have always this as a differential diagnosis in mind while assessing patients who are referred for not recognizing relatives, talking irrelevantly, hallucinating, and having behavioral complaints. It is known in medical literature by different names, such as “acute brain failure, organic brain syndrome, limbic encephalitis/encephalopathy, and ICU psychosis.” It has been seen that nearly 50% of people admitted in the medical and surgical wards of a general hospital are over 65 years of age.[2]
The reasons for which psychiatric consultation is done in acute emergency or ward settings are for sudden onset:
- Altered sensorium
- Agitated, aggressive behavior
- Fluctuations in orientation to time, place, and person
- Behavior and sleep disturbances mostly during late evenings or at night (sun-downing)
- Irrelevant talks
- Uncooperativeness when patient removes intracath or central line, Foley's or ventilatory support
- Perceptual disturbances.
Prevalence of delirium increases with age and hence is usually seen in elderly who are admitted in emergency settings. The prevalence of delirium in elderly persons living in the community overall is low (1%–2%) but increases with age, rising to 14% among individuals older than 85 years.[3]
The factors which predispose or precipitate delirium include the following:
- Age >65 years
- Male gender
- Cognitive status of patient
- Functional status
- Sensory impairment
- Nutritional status
- Comorbid substance use
- Comorbid medical conditions
- Terminal illness
- Hepatic, respiratory, renal, and cardiac impairment
- Fractures, trauma, head injury, surgery
- History of delirium.
The etiology for delirium includes several conditions follows:
- Infections: Sepsis, encephalitis, meningitis, central nervous system abscess, syphilis
- Central nervous system disorders: Seizure disorder, migraine, stroke, hemorrhage, transient ischemic attack
- Trauma: Head injury, burns, fractures
- Metabolic disorders: Electrolyte abnormalities, acidosis, hypoglycemia, hypocalemia
- Systemic illness: Nutritional deficiencies, chronic obstructive pulmonary disease, hypoxia, shock
- Deficiencies: Vitamin B1 and B12 deficiencies
- Endocrinal: Hypothyroidism, diabetes, Cushing's disease, Addison's disease
- Substance abuse: Alcohol withdrawal, cannabis intoxication, opioid intoxication, sedative hypnotics withdrawal
- Toxicity or poisoning: Lead, mercury, carbon monoxide, pesticide
- Medications: Antibiotics, pain medication (morphine), steroids, anticholinergic agents.
The pathophysiology of delirium is as shown in [Table 1].
Clinical features include the following:
- Consciousness: Acute onset of mental status change with fluctuating course, altered consciousness
- Behavioral changes: Disinhibited behavior, shouting in ward, attempting to run away, agitation, aggressive abusive behavior, psychomotor retardation
- Attention deficit: Impairment in following components of attention selectivity
- Selective attention
- Sustaining attention
- Shifting attention.
- Thought and perceptual disturbances: Disorganized thinking, altered perception illusion, hallucinations visual > auditory
- Disturbed sleep wake cycle
- Disorientation and memory impairment
- Floccillation
- Sun-downing
- Liability of affect.
| Types of Delirium | |  |
Hyperactive delirium
Probably the most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations, and refusal to cooperate with care.
Hypoactive delirium
This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness, or seeming to be in a daze.
Mixed delirium
This includes both hyperactive and hypoactive signs and symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.
| Management of Delirium | | |
The management of delirium follows these basic steps: [Figure 1] and [Figure 2].
| Simple Bedside Tests to Diagnose Delirium | | |
Delirium rating scale
It is a 16-item scale which can be used for both diagnosis and rating severity. For diagnosis, there are 3 items rated on Likert scale 0–2 and 13 items for severity for Likert scale rated from 0 to 3.[4]
Time required for estimation is 20–30 min for scoring; higher the score, the more is the severity.
Rating of the patient is generally based on a 24-h time period. It can be administered by psychiatrist, any physician, nurse, and psychologist with adequate training in evaluating phenomenology.
Confusion assessment method
As it is not always possible to asses all points in case of emergency, a simple bedside test can be done which is the is confusion assessment method: The diagnosis of delirium by confusion assessment method requires the presence of features 1 and 2 and either 3 or 4.[5]
Items are as follows:
- Acute onset or fluctuating course - Usually obtained from a family member or nurse and is shown by positive responses to the following questions:
- Is there evidence of an acute change in mental status from the patient's baseline?
- Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
- Inattention - To assess the following questions should be asked:
- Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
- Disorganized thinking
- Was the patient's thinking disorganized or incoherent, unclear, or illogical flow of ideas, or unpredictable switching from subject to subject?
- Altered level of consciousness - How would you rate this patient's level of consciousness?
- Alert (normal), vigilant (hyperalert), lethargic (drowsy, easily aroused), stupor (difficult to arouse), or coma (unarousable).
Other rating scales
- NEECHAM confusion scale [6]
- Intensive care delirium screening checklist.[7]
Basic steps in management are as follows:
Nonpharmacological management
- Ensure that adequate hydration is maintained
- Check for electrolytes, BUN, creatinine, oxygen saturation
- Avoid sleep interruption such as unnecessary monitoring during sleep such as blood pressure and sugar monitoring
- Ask family members to keep patient informing about event as they occur and introduce members regularly to patient to reduce fear and anxiety
- Provide reorientation by clocks, calendars, and well-illuminated room
- Interventions that combine cognitive impairment management, sleep hygiene, early mobility, visual and hearing support, and hydration care (HELP protocol) with light therapy have contributed to significant improvement in functional status
- Interventions that combine cognitive impairment management, sleep hygiene, early mobility, visual and hearing support, and hydration care (HELP protocol) with light therapy have contributed to significant improvement in functional status.[8]
Pharmacological management
- As acetylcholine deficiency is known to precipitate delirium, any drug that is known to have anticholinergic action such as antipsychotics (chlorpromazine, trifluoperazine), antidepressants such as tricyclics, selective serotonin reuptake inhibitors (especially, paroxetine) should be avoided
- Low-dose antipsychotics are found useful in managing acute agitation associated with delirium
- Choice of antipsychotics in delirium include: haloperidol (0.25–1.5 mg), risperidone (0.25–1.5 mg), olanzapine (1.25–2.5 mg), and quetiapine (50–300 mg)
- Quetiapine is most commonly used in treatment of delirium in Indian settings [9]
- Benzodiazepines are useful in managing alcohol withdrawal-related delirium, i.e., delirium tremens [10]
- Cholinesterase inhibitors such as rivastigmine and donepezil have been found useful in management of patients of postoperative delirium.[11]
| Course and Prognosis | | |
Generally, delirium patients recover in less than 1 week and some may take 2 weeks. After removal of causative factor, symptoms usually recede in 3–7 days. Older the patient and longer the duration of hospital stay are some of the factors for extended delirium. Sometimes, delirium may be followed by short period of depressive symptoms and some may have spotty memory of events during course of delirium.
In particular, delirium after remission remains associated with increased risk of functional decline, cognitive dysfunction, and institutional placement and with higher mortality.[13]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Pae CU, Marks DM, Han C, Patkar AA, Masand P. Delirium: Underrecognized and undertreated. Curr Treat Options Neurol 2008;10:386-95.  |
| 2. | Tirupati SN, Punitha RN. Cognitive decline in elderly medical and surgical inpatients. Indian J Psychiatry 2005;47:99-101. [ PUBMED] [Full text] |
| 3. | Sharma A, Malhotra S, Grover S, Jindal SK. Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: A study from India. Gen Hosp Psychiatry 2012;34:639-46. |
| 4. | Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N, et al. Validation of the delirium rating scale-revised-98: Comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 2001;13:229-42. |
| 5. | Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI, et al. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941-8. |
| 6. | Neelon VJ, Champagne MT, Carlson JR, Funk SG. The Neecham confusion scale: Construction, validation, and clinical testing. Nurs Res 1996;45:324-30. |
| 7. | Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Med 2001;27:859-64. |
| 8. | Cerveira CC, Pupo CC, Dos Santos SS, Santos JE. Delirium in the elderly: A systematic review of pharmacological and non-pharmacological treatments. Dement Neuropsychol 2017;11:270-5. |
| 9. | Pinto C. Indian research on acute organic brain syndrome: Delirium. Indian J Psychiatry 2010;52:S139-47. [ PUBMED] [Full text] |
| 10. | Sachdeva A, Choudhary M, Chandra M. Alcohol withdrawal syndrome: Benzodiazepines and beyond. J Clin Diagn Res 2015;9:VE01-7. |
| 11. | Gleason OC. Donepezil for postoperative delirium. Psychosomatics 2003;44:437-8. |
| 12. | Grover S, Avasthi A. Clinical practice guidelines for management of delirium in elderly. Indian J Psychiatry 2018;60:S329-40. |
| 13. | McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK, et al. Delirium in the intensive care unit: Occurrence and clinical course in older patients. J Am Geriatr Soc 2003;51:591-8. |
[Figure 1], [Figure 2]
[Table 1]
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